DOCTORING OLD AGE
A SOCIAL HISTORY OF GERIATRIC MEDICINE IN VICTORIA
Cecily Elizabeth Hunter
Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy
February 2003
Department of History and Philosophy of Science University of Melbourne
ABSTRACT The pattern of medical practice that emerged in Victoria, following the introduction of a national system of publicly subsidised voluntary hospital and medical insurance by the Liberal-Country Party Coalition government in the early 1950s, was dominated by the provision of individualised, curative medical services based upon a reductionist model of disease. Older adults, classified officially as ‘aged’ according to age of eligibility for the Age Pension introduced in 1909 by the Commonwealth government, were prominent in this pattern of practice. The number of adults over the age of sixty-five increased over the early decades of the twentieth century, and the technical advances made in postwar medicine led to a growing clinical engagement with the degenerative diseases associated with old age.
The growing medical involvement with ‘old age’, the basis of the specialist fields of medical practice that proliferated throughout the 1960s, was recognised as such only in relation to the work of general practitioners. Specialist practitioners defined their clinical engagement with old age in terms of pathologies of bodily organs or systems. In contrast, the special role of the GP in relation to elderly patients was defined in terms of that practitioner’s personal knowledge of patients as individuals. Formal designation of the general practitioner as specialist in caring for the sick aged was confined to the Pensioner Medical Service, a component of the national system of remuneration for medical services. Within this pattern of medical practice infirm old people, whose afflictions could not be readily resolved by curative medical services, occupied a residual category outside the field of active medical practice. When poverty compounded the difficulties experienced by these infirm old people they were categorised as a ‘social’ problem to which the appropriate response was the provision of adequate infirmary beds through the charitable efforts of local communities.
This pattern of practice emerged out of decades of internal professional debates, and intermittent negotiations with successive federal governments. Social medicine, particularly as it developed in Britain, was
2 a source of ideas for some participants. However, overall, the emphasis upon fee-for-service reflected a widely held view amongst doctors, of the medical practitioner as an apolitical expert in identifying and treating specific disturbances in individual bodies. In Victoria this view was associated with a long-standing tradition whereby individual doctors, local communities and the colonial/state government cooperated to develop acute hospital services. It was as a background to these developments that the benevolent homes in Victoria, funded largely by the state government and managed by voluntary committees, assumed the role of chronic hospitals. They were repositories for patients unwanted in the general hospitals but without anywhere else to go, and infirm old people, - that residual category, ‘the aged’ – were prominent amongst them. The demarcation in Victorian medical practice, between ‘medical’ and ‘social’ problems ensured this change took place without any alteration in the palliative work of the doctors employed there.
In the professional environment of Victorian medicine, the introduction of a medical role in the management of infirm old people arose out of a policy decision on the part of the Minister for Health, to manage a growing demand for hospitals and increasing public expenditure. John Lindell, appointed first medical chairman of the Hospitals and Charities Commission in the early 1950s, introduced the role of ‘geriatrician’ into the benevolent home environment, as part of a broader process aimed at organising a fragmented array of local hospitals into a state-wide system serving regional populations. Medical services provided by a general practitioner ‘geriatrician’ outside the acute hospitals would enable the ready discharge of infirm old people, following treatment during acute episodes of illness. At the same time these services were aimed to minimise the need for long-term accommodation (another growing area of state government expenditure).
It was, however, events at the national level that influenced the integration of this socio-medical role into the broader profession although under conditions that reinforced the objectives of the Hospitals and Charities Commission. The reform-minded Whitlam Labor government (1972- 1975) funded the development of the socio-medical services promoted by a segment of the medical profession, together with an appropriate
3 knowledge base. This revival of ‘social medicine’ opened up the possibility of integrating the role of ‘geriatrician’ into mainstream medical practice. It did so however, under conditions that meant that geriatric medicine was situated within the broader field of medical rehabilitation on one hand, and on the other hand, the term ‘geriatric service’ referred not so much to the setting for a specialist medical role as to a range of community-based welfare services. The physician geriatrician in Victoria emerged not in response to the specific health problems of elderly people, but as a means of managing increasingly expensive publicly funded hospital services, a response shaped by the organisation of the Australian medical profession.
This is to certify that this thesis comprises only my original work towards the PhD, that due acknowledgment has been made in the text to all other material used and that the thesis is less than 100,000 words exclusive of the bibliography and appendices.
4 ACKNOWLEDGEMENTS
I am very grateful for the consistent encouragement and perceptive guidance of my supervisors, Associate Professor Warwick Anderson, Dr Anna Howe and Associate Professor Janet McCalman. I thank Dr Helen Verran for her encouragement to take up this challenge and Professor Rod Home and Dr Marilys Guillemin for their kind assistance.
Many of the individuals involved in the events described in this thesis have generously given their time to speak to me about their work. These informal conversations were very helpful in enlarging my understanding of the context in which a specialist medical role in treating the infirm aged developed. I would like to thank: Drs D.H. Blake, Herbert Bower, John Hurley, Boyne Russell, Malcolm Scott, and John Shepherd and the late Drs Bruce Ford and Sidney Sax; Professors R.B. Lefroy, Derek Prinsley, and Len Gray and Assoc Prof. Edward Chiu. Dr Shepherd also allowed me the use of his private papers. Mrs Marion Shaw, formerly Executive Officer, Geriatrics Division, Hospitals and Charities Commission, was very helpful in giving me some insight into the work of the Division and, in addition, providing access to the archives of the Australian Association of Gerontology. Miss Shirley Ramsay, one of the first social workers appointed to a position specifically responsible for elderly people, was also generous with her time.
I must also acknowledge my family - Alix, Ben, Faith, John, Justin, Rex – each one has, in his or her own particular fashion, helped me in this endeavour.
5
TABLE OF CONTENTS
ABSTRACT 2 ACKNOWLEDGEMENTS 5
INTRODUCTION 7
CHAPTER 1 30 OLD AGE IN THE PATTERN OF MEDICAL WORK IN VICTORIA
CHAPTER 2 68 THE UNKEMPT GARDEN OF CHRONIC SICKNESS AND INFIRMITY
CHAPTER 3 116 BUREAUCRACY, PHILANTHROPY AND MEDICAL INNOVATION
CHAPTER 4 157 PSYCHIATRY AND OLD AGE
CHAPTER 5 198 GERIATRICS AS MEDICAL WORK
CHAPTER 6 238 PERCEIVING THE ‘SICK MAN’ IN THE OLD PERSON IN TROUBLE
CHAPTER 7 289 MEDICINE OF SENESCENCE OR MANAGING THE SYSTEM?
BIBLIOGRAPHY 316
APPENDICES 348
6 INTRODUCTION
This thesis addresses the question of how it has been possible for health and illness in old age in Victoria to emerge as the focus of a specialist field of medical practice. Superficially, the answer is quite clear: the first attempts to develop a special medical role in the provision of services for the elderly in the late 1950s coincided with the appearance of increasing numbers of elderly individuals in the Victorian population, although proportionately they remained a small group because of the high birthrate and level of immigration. In the period since the early 1970s, when the Australian Geriatrics Society was formed with the aim of promoting geriatric medicine, the proportion of the population classified as ‘aged’ has grown, making the association between the development of geriatric medicine and the shift towards an older population quite explicit.1 It appears only ‘natural’ in these circumstances, that there should develop a geriatric medicine defined as, ‘that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in the elderly’, and that the Society should nominate as its first aim, the promotion of the highest standards of medical care for the aged.2
However, this change in the constitution of the population has meant that, overall, medical practitioners in all fields are concerned with health and illness in old age. The elderly, classified as such on the basis of age of eligibility for the Age Pension, since the 1940s at least have made up a significant proportion of patients in both hospital and community. Since the 1960s, doctors working in specialist areas of practice such as medicine
1 Between 1954 and 1976, the period covered in this thesis, the percentage of the Victorian population aged 65 years and over, changed little, from 8.6 per cent to 8.9 per cent. In absolute numbers the change was more noticeable; 210,000 in 1954 to almost 334,000 in 1976. A high birth rate and sustained immigration accounted for stability in the proportion of the population in this age group, A. Howe, ‘Report of a Survey of Nursing Homes in Melbourne’, Working Paper no 10, October, 1980, p.18. In 1981 the percentage of the Victorian population over the age of 65 was 9.8; in 1991, 11.1; in 1994, 12.1, A. Borowski & G. Hugo, ‘Demographic Trends and Policy Implications’, in Ageing and Social Policy in Australia, eds A. Borowski, S. Encel, E. Ozanne, Cambridge University Press, Cambridge, 1997, p.26, Table 2.1. 2 R.B. Lefroy, ‘The Development of Geriatric Medicine in Australia’, MJA, vol 161, 1994, p.18. The Society began its existence in 1972 as the Australian Geriatrics Society and it is now known as the Australian Society for Geriatric Medicine, for a history of the Society see, R.B. Lefroy, ‘The History of the Geriatric Society of Australia’, in To Follow Knowledge, ed J.C. Wiseman, The Royal Australasian College of Physicians, Sydney, 1988.
7 and surgery have found most of their patients amongst the elderly.3 In general practice, also, there has been a shift in the everyday work of doctors from an emphasis on delivering babies and the diseases of childhood in the postwar period, to a concern with the degenerative conditions associated with advancing age. Indeed the general practitioner is often promoted as the ‘specialist’ in matters relating to health and illness in old age.4 In Victoria, the specialist geriatrician is most likely to provide his or her services in complexes located outside the acute hospitals. In this environment the geriatrician’s role may overlap the general practitioner’s and be difficult to distinguish from that of the specialist in medical rehabilitation who also treats patients whose disabilities arise from the degenerative conditions associated with ageing.
It is the definition of ‘geriatric medicine’ in terms of specialist, age-related expertise in circumstances where problems of health and sickness in old age play such a large part in the overall pattern of medical work, that gives rise to the question at the heart of this thesis. It is a question that addresses the categorisation of old age in Australia and the emergence of specialisation within the work of Australian doctors. This specialisation reflects a range of interactions that are, at the same time, practical, social responses to need and a community acknowledgment of value. The aim of this study is to clarify what it means for medical practitioners to ‘know’ about health and illness in old age in an increasingly fragmented field of medical practice. At the same time I want to identify the consequences of the appearance of age-related medical expertise for social understandings of the experience of growing old and for the expression of public responsibility for the aged members of the community. The concern that animates this thesis is, how has the emergence of this particular field of medical expertise shaped responses in the Victorian community to the
3 The entry on ‘Geriatrics’ in the Companion Encyclopaedia of the History of Medicine, notes that with the exception of the contraceptive pill, ‘all of the major break-throughs in medical technology since the late 1950s, have had their most widespread impact on people who are past their fifties, and the further past their fifties, the greater the impact.’, P. Thane, ‘Geriatrics’, in Companion Encyclopaedia of the History of Medicine, vol 2, eds, W. Bynum & R. Porter, Routledge, London, 1993, p.1110. 4 For example, when Sidney Sax emphasised the importance of the diagnostic process in ensuring that old people get the care they need, he concluded, ‘This is the field in which the family doctor is so clearly able to show the hospital doctor a clean pair of heels’, S. Sax, ‘The Consultation in Geriatric Practice’, Annals of General Practice, September, 1964, pp.172-175; see also an anonymous editorial, ‘Geriatrics’, MJA, vol 1, 1975, p.87.
8 fundamental question as it applies to old age: What shall we do and how shall we live?5
In the decades since Max Weber so succinctly defined the predicament of modern life – how to have a meaningful understanding of life in a world dominated by intellectualisation and rationalisation - social theorists and historians have devoted much attention to explaining the widespread changes that appear to be characteristic of the social life of western, capitalist democracies.6 The concept of ‘professionalisation’ has been developed to describe the predominant form of occupational organisation that has emerged around specific techniques and bodies of knowledge.7 The concept of ‘medicalisation’ has been used to describe the process whereby medical practitioners have become the principal authorities in matters related to health and aspects of everyday life which in other historical periods may have been interpreted in legal or religious terms.8 The process of medicalisation has been linked to a number of aspects of modern society. For Ivan Illich it is associated with the rise of industrial society and the erosion of traditional ways of living.9 The sociologist Eliot Freidson links it to the social power of the medical profession, and feminist theorists extend this notion to emphasise the social dominance of men.10 Other interpretations associate the medicalisation of society with the capitalist mode of production.11 Michel Foucault has interpreted the development of modern medicine as an aspect of the ‘science of
5 Max Weber quotes this question as it was put by Tolstoy, reiterating the point that while science may clarify a particular situation, answering this question is beyond its capacity. M. Weber, ‘Science as a Vocation’ in From Max Weber, eds H.H. Gerth & C. Wright Mills, Routledge & Kegan Paul, London, 1977, p.143. 6 Ibid. p.139. 7 A. Abbott, The System of the Professions, An Essay on the Division of Expert Labor, The University of Chicago Press, Chicago, 1988, Introduction, provides a summary of attempts to develop the concept of professionalisation; see J. Habermas, ‘Technology and Science as “Ideology”’, in Toward a Rational Society, trans J.J. Shapiro, Heinemann Educational Books, London, 1971 for an examination of the questions raised by replacement of a normative social order by technical-operational administration. 8 I.K. Zola, ‘Medicine as an Institution of Social Control’, in The Sociology of Health and Illness, 2nd. edn, eds P. Conrad & R. Kern, St Martins Press, New York, 1981. 9 I. Illich, Limits to Medicine – Medical Nemesis: The Expropriation of Health, Penguin, Harmondsworth, 1976. 10 E. Freidson, Profession of Medicine, Harper & Row, New York, 1970; E. Martin, The Woman in the Body, Oxford University Press, Milton Keynes, 1987. 11 V. Navarro, Crisis, Health and Medicine: A Social Critique, Tavistock, London, 1986; H. Waitkin, The Second Sickness: The Contradictions of Capitalist Health Care, Free Press, New York, 1983.
9 government’ characteristic of modern liberal democracies.12 Williams and Calnan survey a range of responses during the 1980s and 1990s, to earlier formulations of the notion of medicalisation, suggesting that the relationship between medicine and society is more critical and dynamic.13 The sociologist Bryan Turner has responded by proposing the development of a sociology of health and illness to equip the sociologist to contest the process of medicalisation by acting as healer ‘alongside the physician, the psychiatrist and other professional health agents’.14
Charles Rosenberg has suggested that conceptual frameworks like ‘professionalisation’ and medicalisation convey, in general terms, a sense of the interaction between the needs of society and the ‘norms and ideas’ of occupations such as medicine.15 However, they do so with a degree of schematisation that may in fact provide a misleading interpretation of the development of institutions and definitions of legitimacy in specific social settings.16 Henning Kirk’s summary of the emergence of geriatric medicine in the neat formulation of national enterprise – ‘the Germans developed the theoretical framework, the French gave it a clinical impact, and the British demonstrated the results’ - gives some indication of the complexities that may underlie a ‘generic’ geriatrics emerging in response to broad-scale changes in the constitution of modern populations.17 There is nothing haphazard in these complexities: they reflect a range of interactions at the level of the individual, the institution and the system as knowledge-makers negotiate the conditions they require with the society that supports them, as institutions shape the emergence of disciplines and individuals make careers.18
12 M. Foucault, The Birth of the Clinic, trans A.M. Sheridan, Routledge, London, 1971, ‘Governmentality’, in The Foucault Effect, Studies in Governmentality, eds G. Burchill, C. Gordon, P. Miller, The University of Chicago Press, Chicago, 1991. 13 S.J. Williams & M. Calnan, ‘The ‘Limits’ of Medicalization?: Modern Medicine and the Lay Populace in ‘Late’ Modernity’, Social Science and Medicine, vol 42, no 12, 1996, pp.1611-1617. 14 B. Turner, Medical Power and Social Knowledge, 2nd ed, Sage Publications, London, 1995, p.10. 15 C. Rosenberg, ‘Toward an Ecology of Knowledge: On Discipline, Context, and History’, in The Organization of Knowledge in Modern America, 1860-1920, eds A. Oleson & J. Voss, Johns Hopkins University Press, 1979, p.442-3. 16 Ibid. p.442 17 Thane 1993, op. cit; H. Kirk, ‘Geriatric Medicine and the Categorisation of Old Age’, Ageing and Society, vol 12, no 4, 1992, pp.486-489. 18 Rosenberg, 1979 op. cit. p.442-443.
10 Rosenberg makes a similar point about the schematising potential of broad sociological theories in interpreting an apparently changing experience of old age in modern society.19 From the perspective established by conceptual frameworks such as ‘modernisation’, ‘development’ or ‘demographic transition’, a long-term shift has occurred in the course of which the status of the aged has changed so that they are isolated from family and community and any wider system of kinship. The accumulated knowledge resulting from long life experience has become redundant as other forms of knowledge become socially important.20 Historians have responded to the challenge posed by these conceptualisations of ‘old age’ to produce a body of work, covering historical periods from antiquity to modernity in the United States, Britain and Europe, which makes it clear that ‘old age’ varies with the social setting in which it is experienced. Even the most precise of demographic studies is underpinned by a social process in which certain attributes are given to specific age groupings so the study can be made. Pat Thane summarised the position in her survey of the field of historical study of ‘old age’ in 1995. Despite the universal biological characteristics associated with old age – greying hair, wrinkled skin and stiffened joints – the category ‘old people’ is ‘neither single, simple nor continuous’. It is one that is shaped by ideas, class, gender, race and social status.21
As Rosenberg points out, and these studies emphasise, the fit between broad descriptive categories and the data that is available soon becomes obscure.22 Yet there are widespread changes such as that seen in the emergence of ‘retirement’ as a generally experienced period of life in Western societies in the second half of the twentieth century.23 On a smaller scale, the emergence of geriatric medicine as a specialist field of
19 C. Rosenberg, ‘The Aged in a Structured Social Context: Medicine as a Case Study’, in Old Age in a Bureaucratic Society, eds D. Van Tassel & P.N. Stearns, Greenwood Press, Connecticut, 1986. 20 Turner, op. cit. p.127. 21 P. Thane, ‘The Cultural History of Old Age’, in Ageing, Australian Cultural History, no 14, 1995, pp.23-33. 22 Rosenberg, 1986, op. cit. p.231-232. 23 R. Inall, ‘Gerontology, Geriatrics and Retirement’, The Australian Quarterly, 42, no 2, 1970, pp.86-94, is an early attempt to direct the attention of the local ‘gerontology community’ to the ‘problem of retirement’, one aspect of the social and medical problems of ageing. W. Graebner, A History of Retirement, The Meaning and Function of An American Institution, 1885-1878, Yale University Press, New Haven, 1980; L. Hannah, Inventing Retirement, The Development of Occupational Pensions in Britain, Cambridge
11 medical practice in Victoria may be seen as representative of another such widespread shift. Until the late-1970s geriatric medicine in Victoria was developing as a special interest area of general practice. For local purposes, that is staffing the state’s Geriatric Hospitals and providing special interest training and work for general practitioners, this was more or less satisfactory. However, the emergence of an overriding national structure in the organisation of medical practice in which the cultivation of special interests was formalised at the level of consultant specialist, and the growing role of the Commonwealth in funding hospital and welfare services, rendered local solutions superfluous.
Rosenberg has proposed the strategy of using the study of the ‘middle- level social system’ as a means of investigating the links between the type of broad-scale changes that are generalised in concepts such as ‘medicalisation’ and ‘demographic transition’, and the persistence of continuities in specific environments.24 In reference to old age, he nominates three such systems – work, welfare and medicine. The advantage of this approach is that, while the scope of inquiry is limited to a discrete site - hospital or factory for example - that site itself is located within a broader social structure. Focus on the discrete site forces consideration of ‘the ways in which the system’s characteristics relate to each other within the more limited context.’25 The middle-level social system has the potential to expose systemic characteristics, local and mediating characteristics and individual experience. In this thesis, the category ‘old age’ emerges out of the interactions between ‘the medical corps, in the broadest sense of the work, and society; or … physician and patient, whereby, however, the two meet not only as individuals but also as members of society with obligations to it’.26
This thesis then, is an exercise in the social history of medicine, drawing in particular on the social history of specialisation in medicine. The parameters of this diverse, but not extensive field, were first delineated in George Rosen’s study of the development of the specialty of
University Press, Cambridge, 1986; D. Troyansky, ‘Why Do People Retire? Some Historical Answers’, Review Essay, The Gerontologist, vol 39, no 5, 1999, pp.624-626. 24 Rosenberg, op. cit. 1986, p.234ff. 25 Ibid. pp.232-235. 26 H. E. Sigerist, A History of Medicine, vol 1, Primitive and Archaic Medicine, Oxford University Press, New York, 1951, p.15.
12 ophthalmology in the United States, published in the 1940s. Rosen’s study highlighted the part played in shaping medical specialism by the ‘various social forces operating within the medical profession itself, as well (those) impinging on physicians from the larger environment of the society in which they operate’.27 The expansion of knowledge and the development of techniques were but one aspect of a situation in which many factors combined to make specialisation in the field of diseases of the eye possible. The potential patient base in the population of a large city was important, as was the willingness of the public to pay for specialist services, the benefits of which were readily demonstrated in ophthalmology. Competition between doctors for paying patients meant that market forces played a considerable part in shaping specialist practice, leading to a proliferation of medical organisations formed to supervise accreditation and training. The tradition of charitable provision of medical services for the poor also contributed to the development of the institutional settings in which skills were developed and practitioners trained.28
Despite Rosen’s clear acknowledgment of the complexity of the circumstances in which this specialist field of medical practice emerged, the structure of his work - into chapters concerned with specialisation amongst ‘primitive’ people, with the ‘logic’ of nineteenth century medicine and with the social background - suggests a privileging of ‘scientific’ medicine. Rosemary Stevens’ studies of specialisation in England and the United States, published 1966 and 1971 respectively, also suggest that specialisation is driven primarily by advances in medical knowledge.29 Nevertheless, in both cases, the context in which this claim is made makes it clear that these advances are embedded in specific historical circumstances. Stevens makes the point herself, in the introduction to a new edition of the American study, that science and technology cannot be regarded as ‘independent constructs’ that underpin
27 G. Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology, Arno Press & The New York Times, New York, 1972, p.30. 28 Ibid. p.62ff. 29 R. Stevens, Medical Practice in Modern England, The Impact of Specialization and State Medicine, Yale University Press, New Haven, 1966, p.4, American Medicine and the Public Interest, A History of Specialization, Updated Edition, University of California Press, Berkeley, 1998 (first published in 1971), p.xv.
13 the specialisation process.30 Her subsequent essay on the development of internal medicine in America clarifies this point. The persistence of this ‘late and reluctant entry to specialty certification’ is due to the strategic skills of its advocates. They have promoted their interests by stressing their generalist and humanistic orientation in a fragmented profession, and their capacity to deal with uncertainty in a professional climate where decisions about treatment have become less clear-cut.31
Two other studies of specialisation in American medicine highlight the part played by ‘social’ factors in the specialisation of medicine. In a profession that is open to market forces, status and effective organisation underpin the emergence and persistence of the specialist field of practice.32 Sydney Halpern’s historical sociology of the specialty of paediatrics side- steps the knowledge-making aspect of paediatrics by making a distinction, which she notes is not free from ambiguity, between specialties that are associated with scientific advances and those that are ‘social-problem based fields of medical expertise.33 Glenn Gritzer and Arnold Arluke suggest that in a competitive market for professional services, knowledge and technology can be resources used by groups to justify their claim to specialty status and dominance in a division of labour.34
In contrast to the studies of paediatrics and medical rehabilitation which concentrate on the organisational aspects of specialisation, Judith Walzer Leavitt provides a seamless account in which the practices that define the specialty of obstetrics emerge out of an evolving interrelationship between medical practitioners and well-to-do childbearing women.35 Leavitt concludes that the knowledge and techniques that define twentieth-century obstetrics were forged within a confluence of medical ideas and practices - and women’s disposition to control the experience of childbirth through
30 Stevens, op. cit. 1998, p.xv. 31 R. Stevens, ‘The Curious Career of Internal Medicine: Functional Ambivalence, Social Success’, in Grand Rounds, One Hundred Years of Internal Medicine, eds R.C. Maulitz & D.E. Long, University of Pennsylvania Press, Philadelplia, 1988, pp.357-364. 32 G. Gritizer & A. Arluke, The Making of Rehabilitation, A Political Economy of Medical Specialization, 1890-1980, University of California Press, Berkeley, 1985; S. Halpern, American Pediatrics, The Social Dynamics of Professionalism, 1880-1980, University of California Press, Berkeley, 1988. 33 Halpern, op. cit. p.11-12. 34 Gritzer & Arluke, p.7. 35 J. Walzer Leavitt, Brought to Bed, Childbearing in America, 1750-1950, Oxford University Press, New York, 1986.
14 the choices they made - in a social context characterised by growing affluence, social fragmentation and a propensity to look to ‘science’ as an authority.36 The relationship, as Leavitt acknowledges, was not an equal one, nevertheless, by the 1950s, a ‘social norm’ of childbirth was established within a relatively stable network of associations, the stability of which depended on both women and doctors being able to play their part.37
The study of specialisation in British medicine offers a different perspective from that in the United States, as the organisation of medical practice there leaves less scope for the operation of market forces. Thus Christopher Lawrence’s study of the shift in perspective that underpinned the emergence of cardiology as a specialist field of practice between 1880 and 1930, encompasses ideas, medical associations, techniques, institutions and changing attitudes regarding the clinical practice of medicine and the use of technology.38 In a closed medical world where specialisation in practice developed within an existing division of medical labour between general practitioners and consultant physicians and surgeons, and where access to specialists came through referral from the general practitioner, the most pressing task facing medical innovators was to convince their colleagues and hospital governors of the merits of proposed innovations.39 The scope for developing innovations in the course of providing medical care for the indigent patients who filled the wards of the voluntary hospitals was extended during the First World War when the War Office officially recognised the special categories of disease perceived within the ‘new cardiology’ and appointed men with special abilities to deal with these problems.40
36 Ibid, pp.207-212. 37 B. Latour, Science in Action, Open University Press, Milton Keynes, England, 1987, p.256. Leavitt’s review essay, ‘Medicine in Context’ displays a growing field of scholarship defined not by the ‘particular approach, training or departmental affiliation of (the) practitioner’ but by subject matter, the processes of healing and their meaning, J. Walzer Leavitt, ‘Medicine in Context’, American Historical Review, vol 195, no 5, December, 1990, p.1473. 38 C. Lawrence, ‘Moderns and Ancients: The ‘New Cardiology” in Britain 1880-1930’ in The Emergence of Modern Cardiology, eds W.F. Bynum, C. Lawrence, V Nutton, Medical History, Supplement No 5, 1985, Wellcome Institute for the History of Medicine, London. 39 A leading participant in the process was James Mackenzie, a general practitioner who wanted to establish general practice as the seat of clinical research, who viewed hospital medicine and specialisation as necessary evils, and who believed the instruments developed in a physiological approach to heart disease would, in the long run be jettisoned in favour of the clinical skills of the doctor, ibid, p.15-16, p.21ff. 40 Ibid. p.21.
15
Roger Cooter has focused on the period he calls the ‘adolescence’ of orthopaedics to highlight the ‘interrelations between society, economy and medical politics’ that underpinned the emergence of this specialist field of practice.41 During a period when it was far from clear that orthopaedists could justify their claims to specialist status in terms of specific expertise, it was the capacity of these practitioners to align their interests with other social groups that led to their being in a position to claim specialist status. These social groups included industrialists, trade unions, charity organisations and officers of the state in times of peace and war. Orthopaedists achieved a position of authority through their involvement in a range of social issues (similar to the paediatricians Halpern studied). They did so however, not as ‘science-or technology-wielding professionalizers, nor as policy informing medical politicians’, but as ‘ideologues of corporatism, rationalisation, and statism: at a time when the state was reaching out to embrace professionals in its effort to efficiently manage its welfare’.42 The end product of this process, the post-National- Health ‘specialty’, was negotiated as orthopaedists tried to align their claim to a ‘generalist’ expertise in restoring function to impaired productive social units – workers, soldiers, disabled children – with the possibilities for existing as a specialist field of medical practice within the National Health Service.
With the introduction of National Health Service medical practitioners at the level of consultant gained a degree of control over the regional allocation of central government resources and to this extent orthopaedists had achieved their managerial aims. The authority of local government officials and lay hospital governors was diminished and consultants were recognised as a privileged elite. However where previously orthopaedists had been able to justify their claim for authority by reference to their standing as medical practitioners and their technical expertise, now they had to establish a claim to authority that was recognised within the medical profession. Securing and holding a footing in the medical
41 R. Cooter, Surgery and Society in Peace and War, Orthopaedics and the Organization of Modern Medicine, 1880-1948, Macmillan, Basingstoke, 1993, p.4. 42 Ibid. p.6.
16 hierarchy – that is in the university medical schools - meant abandoning a ‘social’ and ‘low-tech’ profile and justifying their role in terms of scientific and technological research. In the late 1940s when British orthopaedists set off to do this by visiting leading orthopaedic centres in America, the past history of the specialty was denigrated, ‘it had foolishly inverted its constitution, and ‘put art before science’.’ 43
There are no studies of the practice of medicine in Australia that are comparable to Cooter’s examination of the interactions between society, profession and state that underpin the modern specialty of orthopaedics. Neville Hicks noted in 1982 that some general historians of institutions have paid attention to the context in which medical practices and ideas have been developed and established, but on the whole the social history of medicine has received limited attention.44 The situation has changed little since then. Hicks commended T.S. Pensabene for bringing the skills of the economic historian to bear on the question of how doctors in Victoria have achieved the position of being the principal authority in matters relating to health and illness.45 Pensabene, who was influenced by Henry Sigerist’s approach to the history of medicine, concluded that it was the strength of their professional organisation that made it possible for advances in medical knowledge to contribute to the rising status of doctors in Victoria in the eyes of the lay public, and that made it possible for the profession to establish a relationship with the state so doctors controlled
43 Ibid. p.237-238. 44 N. Hicks, ‘Medical History and History of Medicine’, in New History, Studying Australia Today, ed G. Osborne & W.F. Mandle, George Allen & Unwin, Sydney, 1982, p77. Possibly Hicks himself was more intent on questioning the power of the medical profession than promoting inquiry into how medical knowledge emerged as a social process. His own work, ‘This Sin and Scandal’: Australia’s Population Debate, 1891- 1911, Australian National University Press, Canberra, 1978, a study of the debate about population decline in Australian in the early years of the twentieth century, indicates that he believed that there was some empirical reality that was distorted by social interests. In this case, the conservative moralists who dominated the inquiry, ‘The Mackellar Commission provided a forum which some of them (‘men with a grip on the past’) used in a manner inimical to the discovery of evidence …’, p.157. 45 T.S. Pensabene, The Rise of the Medical Practitioner in Victoria, The Australian National University, Canberra, 1980, p.1-2.
17 the conditions in which legitimate health services were provided.46 However, just as Rosen’s study of specialisation in America is based on an implicit division between the context of medical knowledge and its content, so is this study by Pensabene.
Evan Willis brought a Marxist interpretation to the question of how the medical profession became dominant in the division of labour around health services.47 He concluded that the emergence of ‘scientific medicine’, a field of practice ‘carried out by graduates of training institutions which teach the scientific, clinical and research orientations of the occupation known as the Australian Medical Association’ paralleled a long-term shift in Australia from ‘laissez-faire to monopoly capitalism’. The focus on individual and biological phenomena in the paradigm associated with ‘scientific’ medicine, and the exclusion of the political and social elements in illness, contributed to the conditions that were required for maintaining the production and reproduction of capital.48 Willis also appears to recognise an underlying ‘scientific’ reality in answering the question of how ‘certain sorts of knowledge gain class and state patronage so as to permit the holders of that knowledge to achieve a position of dominance’. He does this by making a distinction between ideology and science and showing that scientific and technological elements ‘intruded’ on the political process through which the medical profession achieved its dominant position.49
Pensabene’s and Willis’ studies illustrate Rosenberg’s point that the frameworks provided by generalisations such as, in this case, professional autonomy and the operation of the capitalist mode of production, obscure the ‘fine’ structure of the interactions ‘between knowledge and the society that supports its accumulators and practitioners’.50 J.A. Gillespie addresses the questions raised by such generalisations in his study of the events that led to the introduction of the National Health Service by the
46 Ibid. p1-2, pp.177-179. 47 E. Willis, Medical Dominance, The Division of Labour in Australian Health Care, Allen & Unwin, Sydney, 1983. 48 Ibid. p.20ff. 49 Ibid. p.90. 50 Rosenberg, op. cit. 1979, p.442.
18 Menzies’ government in the early 1950s.51 Asking why the matter of remuneration for medical services has loomed so large in medical concerns, Gillespie uncovers a range of complex interactions within profession concerning relations with the state and the content and organisation of medical services, and outside it as the federal government, according to the political orientation of the party in power, sought to control a growing involvement in funding health services, while at the same time bringing lay understandings of the form health services should take into the public arena.
The medical profession did emerge as a dominant force in the National Health Service that was introduced in the early 1950s. However, it did so within a broad consensus about the form health services ought to take; a consensus that included doctors and politicians and one that existed alongside political differences about how hospital and medical services should be paid for. Lay support for a specific model of medical practice underpinned professional dominance and obscured intra-professional dissension on this matter. The dominance achieved by the Australian medical profession in the 1950s was further tempered by the requirement for fiscal responsibility on the part of the Federal government regardless of what party was in power.52
Gillespie’s study is useful for this examination of the conditions in which geriatric medicine emerged as a specialist field of practice in Victoria for two reasons. First, it provides an example of the type of study Rosenberg calls for, one that identified the specificity of the linkages that are established in the course of broad-scale changes in the organisation of social life, changes that are represented in concepts such as ‘professionalisation’ and ‘medicalisation’. Gillespie’s work highlights the strength of lay knowledges and the often contradictory relationships within medicine and between medicine and the community that supported it, as
51 J.A. Gillespie, The Price of Health, Australian Governments and Medical Politics 1910- 1960, Cambridge University Press, Cambridge, 1991. 52 Ibid. p.234ff
19 the state became more involved in the funding and provision of health services in Australia and the medical profession assumed a dominant role in their organisation.
Gillespie’s work is also important for this study of the emergence of the specialty of geriatric medicine because it shows that the development of a medical role in providing age-related services was lodged within a long- standing, although intermittent, debate within the medical profession about the organisation, orientation and funding of health services. The emphasis on individualised, curative medical services in the organisation of medical practice that was established in the early 1950s represented the defeat of another, potentially complementary, orientation to the provision of health services, one which can be loosely described by the term ‘social medicine’. This term will be discussed in detail in chapter two but in general, social medicine, as it was understood by Australian doctors in the first half of the twentieth century, referred to the provision of publicly funded health services focused on prevention and rehabilitation, salaried medical service and an interpretation of illness and disability that recognised the multi-causal nature of ill-health. When the opportunity arose in the mid-1970s, for the advocates of geriatric medicine to develop their field of practice, it did so in a political environment favourable to the public provision of medical services, and a professional context where ‘social medicine’ was beginning to be accepted as a legitimate approach to managing disease and disability. Twenty years later when geriatricians lamented the slow development of their specialty, citing the association with benevolent homes, fee-for-service forms of remuneration for medical services, and Commonwealth legislation for age-specific welfare measures, they were identifying long-standing problems associated with integrating a ‘social medicine’ perspective into the mind-set of the Australian medical profession.
There is little in the history of old age in Australia to draw upon in this examination of the relationship between medicine and old age in Victoria. If the historical study of old age has been slow to develop in other countries, it has been almost non-existent in Australia.53 The most
53 For a survey of this work see, D. Troyansky, ‘Progress Report, The History of Old Age in the Western World’, Ageing and Society, 16, 1996.
20 sustained attention to this topic occurred in 1995 when the editors of Australian Cultural History published a collection of essays under the title Ageing.54 Local contributors to this volume suggested there was an association between the social categorisation of ‘old age’ and poverty, and identified a form of ‘ageism’ in a colonial society infused with ideas of youthfulness and nation-building.55 In this latter respect the building of a ‘modern’ society on very old Australian soil, was accompanied with a similar denigration of old age that historians have discerned in the processes that accompanied the emergence of the Republic of the United States of America.56 A subsequent paper by Dawn Peel, reporting on the experiences of a cohort of early settlers in country-Victoria, highlighted the problem of defining what is meant by ‘old age’ and the variety of experience in the lives of ageing adults.57 She did not aim to establish linkages between local changes and the type of broad-scale shifts in social organisation that historians of old age in the United States have sought to demonstrate. Prior to the publication of this edition of Australian Cultural History, most material related to old age was to be found in the histories of charitable provision for the poor and welfare legislation, an association that suggests a long-standing link between old age and poverty but so far the relationship has not been closely examined.58
In the general lack of attention on the part of Australian historians to the categorisation of ‘old age’ there has been no direct attention to the role of medicine in this process.59 Consequently the background for this examination of the emergence of a specialist medical role in relation to health and illness in old age in Victoria, is set entirely by studies relating to other countries. In general, historians have drawn on medical ideas about health and illness in old age to reconstruct representations of old age
54 ‘Ageing’, Australian Cultural History, no 14, 1995, eds D. Walker & S. Garton. 55 G. Davison, ‘Our Youth is Spent and Our Backs are Bent’; G. Karskens, ‘Declining Life: On the Rocks in Early Sydney’; S. Cooke, ‘Terminal Old Age’. 56 D.H. Fischer, Growing Old in America, Oxford University Press, New York, 1978, p.111. 57 D. Peel, ‘Towards a History of Old Age in Australia’, Australian Historical Studies, vol 117, 2001, pp.257-275. 58 T.H. Kewley, Social Security in Australia, 1900-1972, 2nd. edn Sydney University Press, Sydney, 1973; B. Dickey, No Charity There, A Short History of Social Welfare in Australia, Nelson, West Melbourne, Victoria 1980; S. Garton, Out of Luck, Poor Australians and Social Welfare, 1788-1988, Allen & Unwin, Sydney, 1990. 59 Graeme Davison is an exception to the extent that he does draw on the ideas of Dr Philip Muskett in completing his picture of old age as the new Commonwealth of Australia was established, Davision, op. cit. p.53-54.
21 at various periods, in Europe, North America and England.60 In addition some historians have identified a role for medicine in the ‘ageism’ they have associated with the long-term historical movement in which modern society emerged with its emphasis on innovation and competition, market economy and fragmented social life. From this perspective the introduction of age-related welfare measures such as old age pensions have also played their part in stigmatising old people in modern society.61
Thomas Cole has used medical texts, amongst a range of textual material, to illustrate a shift in the conceptualisation of old age in American society in the last decades of the nineteenth century. This change meant that old age was represented not as the end of a spiritual journey in the life of the virtuous Protestant, but as a period when the middle-aged self required reconstruction under the tutelage of scientists and the helping professions.62 The limitations of projects such as Coles’, is that in focusing on ideas about old age the question of how these ideas are actually received is not considered.
Carole Haber has also discerned a shift in ideas about old age in America from around the late nineteenth century. She also sees a role for medicine in this process as American doctors took up the ideas developed in the French and German hospitals (ideas that are, in general, nominated as the beginning of ‘geriatric medicine’).63 Thus I.L. Nascher ’s construction of ‘geriatrics’, in America, the medical specialty concerned with health and illness in old age, played a leading part in formalising a body of ‘scientific’ medical knowledge related to old age and the emergence of professional expertise in the field of care of the aged.64 From Haber’s perspective, the formalisation of medical ideas about old age at the end of
60 G. Minois, History of Old Age, From Antiquity to the Renaissance, trans S. Hanbury Tenison, Polity Press, Cambridge, 1989; H.J. Von Kondratowitz, ‘The Medicalization of Old Age, Continuity and Change in Germany from the Late Eighteenth to the Early Twentieth Century’, in Life, Death & The Elderly, Historical Perspectives, eds M. Pelling & R.M. Smith, Routledge, London, 1991; Kirk, op. cit. pp.483-497. 61 Fischer, op. cit. p.109. 62 T. Cole, The Journey of Life, A Cultural History of Aging in America, Cambridge University Press, Cambridge, 1993, pp.220-222. 63 See, for example, M.D. Grmek, On Ageing and Old Age, Basic Problems and Historic Aspects of Gerontology and Geriatrics, Vitgeveris W. Junk, The Hague, 1959. 64 C. Haber, Beyond Sixty-Five, The Dilemma of Old Age in America’s Past, Cambridge University Press, Cambridge, 1983.
22 the nineteenth century and the beginning of the twentieth, contributed to a growing public view of old age as a period of unrelievable decrepitude, requiring special institutional arrangements in the form of housing and pensions, organised under the supervision of expert professionals.
However, Haber develops her argument by reference to measures introduced specifically to address the needs of poor old people or the working class with limited resources. This approach raises the question of whether the medical model in which old age was represented as a period of decrepitude was one that was class-based. While it seems clear from the evidence Haber provides that there was a shift in social ideas about old age, even if they were confined to the lower classes, the interactions between medicine and society in which it was embedded are obscured in the broad-ranging approach she adopts. For example were the physicians who began to exclude elderly patients from the Wisconsin State Hospital for the Insane, patients they had been prepared to admit at younger ages, acting simply under the influence of a medical model in which old age was represented pessimistically or were there other influences?65 Had requests for admission increased, were resources limited, were these paying patients? These questions are not addressed. Nor is it clear how the small group of doctors who promoted geriatrics as a field of specialist expertise could be so unsuccessful professionally and yet so influential in shaping the ideas of other doctors.66
Peter Stearns’ history of old age in France comes closest to a social history of medicine perspective and it is one that seeks to link broad-scale social change with the experiences of ageing adults. In one of the earliest of the studies of old age that began to appear in the 1970s, Stearns examines the changing experience of old age in France, in the period from mid- nineteenth century into the early decades of the twentieth, including medical responses to the problems of ill-health experienced by these people.67 Stearns dissects a medical ‘cake’ constructed during this period as medical knowledge about health and illness in old age emerged as a
65 Ibid. p.90. 66 C. Haber, ‘Geriatrics: A Specialty in Search of Specialists’, in Old Age in a Bureaucratic Society, eds D. van Tassal & P.N. Stearns, Greenwood Press, Connecticut, 1986, p79. 67 P. Stearns, Old Age in European Society, The Case of France, Holmes & Meier Publishers, New York, 1976, Chapter Three.
23 specialist field in the work of physician researchers (whose work was done in institutions set up to house the indigent and sick aged), and a growing population of elderly people, benefiting from improved social and economic conditions, actively sought relief from the ailments they experienced from doctors working in the community.
Until the twentieth century doctors in everyday medical practice contributed little to the remedies used by old people either because more elderly people lived in the country where doctors were fewer, or because they did not have much to offer. When doctors were able to offer successful treatments, they had been developed, not by the researchers in geriatric medicine, but in other areas such as endocrinology and the treatment of infections. Often their use in the treatment of the elderly occurred in response to demands by patients who were more aware of innovations that were available than were their doctors.
Stearns’ examination shows that medical practitioners were closely involved in the efforts made by a growing number of elderly people to deal with problems of ill-health they experienced. These were not the specialists in geriatric medicine however, but the doctors in everyday practice. The early theoretical advances by French doctors did not affect the lives of most old people and they were soon overtaken by the work of researchers in other countries. This medical ‘cake’ emerged as part of a long-term shift in the constitution of the French population, and changing social and economic circumstances. Ageing adults contributed to its content as they sought to adjust to old age by making demands upon medical attendants. The greatest influence of the specialist researchers in geriatric medicine was to enhance an existing pessimism in French culture, about old age. The pessimism of practising doctors was tempered by their contact with healthy and active old people and they were obliged to take a more active stance in relation to old age infirmity by the refusal of old people themselves to accept the difficulties they experienced. Stearns shows how medicine both worked with a new experience of old age and worked against it, but also that the more prominent representation of elderly people in a population did not necessarily lead to a strong field of specialisation in the medicine of old age.
24 Stearns’ interpretation of the involvement of medicine in the categorisation of old age indicates that the intersection of medical knowledge and a changing experience of old age is more complex than Haber suggests as she links the marginalisation of old people, a process characteristic of ‘modernity’ and the emergence of geriatric medicine. Stearns also associates a pessimistic view of old age with the development of geriatric medicine but at the same time shows how little geriatric medicine had to do with the experience of most ageing men and women in France. Pat Thane’s history of old age in England, over a period from medieval times to the present, makes a point similar to Haber’s.68 Thane suggests that in emphasising the special characteristics of ill-health in old age some of the early practitioners in the field of ‘geriatrics’ may have contributed to a general view that the elderly were difficult and unrewarding patients.69 However, like Stearns, Thane also makes the point that the medical contribution to a changing experience of old age in the twentieth century came, not from specialists in geriatric medicine, but from other fields of medical practice.70
The advantage of Thane’s work is that these observations are lodged within a perspective built up in the course of a survey of processes that shaped the categorisation of old age in a single culture, over a long period of time. The category ‘old age’ is shown to emerge out of the social and political interactions around community responses to a range of matters – poverty, work, and family life. These responses are enlivened by the reflections of old people themselves on the condition of old age, and by the representations of old age that emerge out of, and are used to justify these endeavours. Thane’s work is important for the purposes of this thesis, not only because of the close historical links between England and Victoria, in relation to medicine and welfare. More importantly, the broad sweep of her study highlights the systemic changes that underpin shifts in the experience of old age and public understanding of it. For example, the dependence of some old people on publicly funded welfare is ‘not a
68 P. Thane, Old Age in English History, Past Experiences, Present Issues, Oxford University Press, Oxford, 2000. 69 Ibid, p.450. 70 Ibid. p.458ff; see also Thane 1993, op. cit.
25 twentieth century invention’, but the social and political environment of the twentieth century ensures that old age is represented in a qualitatively different fashion from the representations that accompanied Poor Law relief.71 The latter was associated with conditions under which the recipients were excluded from the right to vote. Poverty relief measures in the twentieth-century measures were not associated with exclusion from participation in political activity and thus worked, albeit imperfectly, to include the recipients in everyday social and political life. Poor Law relief was funded and administered by local communities so to the extent that they represented a public understanding of old age, it was a fragmented and local understanding. In mid-twentieth-century, local understandings of old age were gradually superseded as a ‘specific set of widely held images of elderly people’ emerged along with a range of age-related welfare measures. As the British government addressed concerns about the effects of a longstanding low birth-rate, and the operation of a publicly funded, universal health service, old age emerged as a specific and universal, ‘stage of life’, with its associated normative characteristics.72 In identifying continuities and discontinuities over a long period of time Thane sets the scene for investigations into the ‘linked changes between the most general aspects of social and economic organisations and the smaller worlds of the school, the factory, the business firm, the hospital’.73
This investigation of the network of associations from which geriatric medicine emerged in the late 1970s as a specific field of medical practice is initiated in chapter one. Here the point is made that in the pattern of medical practice in Victoria, in the early 1950s, ‘the aged’ were most likely to be those individuals who were poor, dependent on publicly funded care, and whose afflictions could not be cured by individualised medical services. This ‘framing’ of old age combined a longstanding view in the general population that the adjective ‘old’ was more appropriately applied to those who occupied the lowest rungs of the social ladder, a community proclivity to see the poor aged as worthy objects of charity, and a general community view that the provision of individualised,
71 Ibid. p.7-8. 72 S. Harper & P. Thane, ‘The Consolidation of ‘Old Age’ as a Phase of Life, 1945-1965’, in Growing Old in the Twentieth Century, ed M. Jeffreys, Routledge, London, 1989. 73 Rosenberg, 1986, op. cit. p.232.
26 curative medical services was the best approach to managing problems of ill-health.
The second chapter examines the ideas and institutions that underpinned this view of old age infirmity. It does so by tracing the reception of ideas associated with social medicine by the Australian medical profession and the attempts made to implement a local interpretation of this approach in the provision of medical services. This outline of social medicine is amplified by an account of institutional changes in Victoria from the 1920s to the 1950s. The intention is to show that, in Victoria, ‘social medicine’ was absorbed into a set of interactions surrounding the provision of hospital services. The medical profession sought to establish the public hospitals as training and research institutions. The community continued its tradition of involvement in providing hospitals. The state government, facing an increased demand for hospitals by a burgeoning postwar population, took the first tentative steps in abandoning a role limited to supervising the use of public funding by community groups as they responded to their own perceptions of need, and replacing it with policy driven funding programs for a system of hospital services.
The third chapter is concerned with the introduction of a medical model into a longstanding tradition of charitable provision for the aged. This enlargement of the medical role led, not to the dominance of medicine, but to an enhancement of community activities in caring for the aged and infirm by the introduction of special forms of expertise in administration and services. Chapter four deals separately with the introduction of services for the infirm aged into psychiatric services, a specialism entailed not by the needs of this patient group, but by the division of hospital services between physical and mental illness.
Chapter five situates Victorian developments in the provision of ‘geriatric services’ and the medical role of ‘geriatrician’ within a national context. This is necessary because while the Victorian general practitioners who established this role were satisfied to work within a local framework, their physician colleagues in other states took a broader view. The possibility for establishing geriatric medicine as a specialist field of practice at consultant level arose out of the actions taken by doctors in other states as
27 they sought to achieve acceptance within the profession and at the level of government, for publicly funded, socio-medical services to complement the medical services provided in the acute hospitals. These were oriented towards the complex needs of the chronically ill and disabled and emphasised prevention, rehabilitation and the incorporation of the services of a range of health professionals. The early 1970s saw a revival of the ideas associated with social medicine and their implementation in a specifically local form. Chapter six examines this process in Victoria as local interests adapted it to address the needs of the infirm aged. Local ‘geriatricians’ played a minor part in the process through which the role of specialist physician geriatrician emerged. This role was shaped instead by the concern of the state bureaucracy to make the most efficient use of public facilities, by federal funding provisions that defined geriatrics as the provision of community-based services, and by the opportunistic actions of parties ready to support geriatric medicine as a means of promoting their own interests.
This thesis is limited in the contribution it can make to understanding the experience of old age in Victoria in the last half of the twentieth century. The people who were the focus of attention in the developments recounted here, can only be taken as representative of ‘the aged’ in the sense that they were over the age of eligibility for the Age Pension - the predominant mode of separating out the aged from other adults during this period. They are, on the whole, silent participants in the construction of a field of medical practice around health and illness in old age. Furthermore they are only a segment of the category ‘old people’; a segment that, because of infirmity and often poverty, was obliged to seek publicly funded assistance of one kind or another.
On the other hand this examination of the conditions in which the role of the specialist physician geriatrician emerged does offer some insights that are relevant to policy making in relation to hospital services and provisions to assist the dependent members of society. First it raises the question of whether age-specific measures are the best approach to dealing with problems of illness and dependency. Health and activity in old age have become a more common experience throughout the course of the twentieth century because of general social and economic improvements
28 and it has been within an ‘ageless’ model of disease that advances have been made in dealing with the degenerative conditions associated with ageing. Nevertheless the needs of some old people were not met in the way hospital and medical services were organised but recognition of these needs was obscured as specific interest groups in Victoria took up the generalised ‘problem of old age’ as it was elaborated in other countries. Relatively straightforward measures such as the provision of appropriate acute care hospital services for those old people at risk of needing custodial care, in addition to coordinated domiciliary services, were submerged in the undifferentiated mass of the ‘problem of old age’.
29 CHAPTER 1 OLD AGE IN THE PATTERN OF MEDICAL WORK IN VICTORIA
Introduction
The following exploration of how old people figured in the work of Victorian doctors in the 1950s covers a ‘mundane’ territory where doctors dealt with patients whose afflictions were not readily resolved by death or cure. Beginning early in the twentieth century this chapter traces a process in which the organisation of medical practice in Victoria and a changing experience of old age are intertwined. This multi-faceted process encompassed the emergence of an official definition of old age in Australian society, public provision of health and welfare services, the emergence of a reductionist interpretation of sickness in the Australian medical profession and the associated responses to problems that were not amenable to this approach.
As medical practitioners deployed their ingenuity and entrepreneurial skills in applying the therapeutic advances made in medicine in the first half of the twentieth century, ageing adults benefited. They did so however, not because doctors advanced in their understanding of the actual ageing process, but because they advanced in their mastery of technique and knowledge of pathological processes. The same approach had led to greater skill and effectiveness in treating illness in the very young. It was when these technical skills failed to restore elderly patients to good health that their condition was accounted for in terms of ‘old age’ – a residual category awaiting further advances in medical skill. The most visible group in this category were the patients in the public hospitals who could not be discharged because they had nowhere to go.
Even as ‘old age’ emerged as a residual category in medical practice, some general practitioners began to nominate the medical care of the ‘the elderly’ as a specific aspect of general practice. This emphasis on age was prompted by the appearance of a range of texts, produced mainly in the United States from the late 1930s onwards. Some focused on health and illness in older adults, and others reported the results of a growing field of
30 research into various aspects of the ageing process. When the Australian College of General Practitioners was established in the late 1950s the possibility arose of formalising education and training relating to the medical care of older adults. As it was, the clearest indication that the general practitioner was emerging as the specialist in relation to health and illness in old age in the 1950s was found in the Pensioner Medical Service. Introduced in 1951 as one element in the system of hospital and medical insurance established by the Menzies government, it remunerated general practitioners for medical services provided to eligible pensioners. Specialist services were not included; pensioners had to attend one of the public hospitals for specialist attention. At the same time as age was beginning to be eliminated as a factor in therapeutic decisions, it was increasingly emphasised in social life. The Pensioner Medical Service was one of a number of age-specific welfare measures that appeared in the 1950s to contribute to a process whereby ‘the aged’ were increasingly marked out as a specific social group.
While the ailments of ageing adults played a larger part in the everyday work of doctors the medical profession in Victoria was unanimous in the view that the infirm aged, unless in the acute stage of a disease process, had no place in active medical work. This point of view was made clear by Dr Alan McCutcheon, medical officer at Mount Royal Home and Hospital for the Aged, at the Australasian Medical Congress in Melbourne in 1952, where for the first time there was a session on the ‘medical care of the aged’.1 McCutcheon referred to a group of elderly patients, the long-term sick and irremediable, whose needs were to be met through the provision of hospital beds that were distinguished from those in the general hospitals by being less costly. Where medical and lay opinion were beginning to diverge on the matter of what conditions associated with old age were treatable (other contributors to this session emphasised this point), they shared the view that the provision of long-term care beds was the most appropriate response to the needs of infirm old people.
McCutcheon’s description of the needs of this group as a social problem, not a medical one, therefore reflected community and professional
1 MJA, vol 2, 1952, p.489-490.
31 opinion. His use of the term ‘geriatrics’ to refer to this group and the ‘problem’ implied an inherent link between the needs of this group and old age in general. However poverty and dependence may have been just as prominent in the plight of these unfortunates, and the group did include younger adults as well as those past the age of eligibility for the Age Pension, the existing public definition of old age. Posing this problem in such terms arose as much from the existing proclivity in the Victorian community to emphasise the ‘aged’ as having a special place in community responsibilities, as from any other factor.
The professional setting in which McCutcheon defined the infirm aged as a ‘social’ and not a ‘medical’ problem became more clearly defined in the 1950s. The roles of specialist and general practitioner were more clearly demarcated and the hospital and medical insurance scheme introduced by the Menzies government provided an assured system of remuneration. The ‘new order’ reinforced professional autonomy over the conditions of providing medical services and emphasised the provision of individualised, curative medical care. It also entailed a greater involvement on the part of the federal government in subsidising such services, which, in relation to hospitals, had previously been the responsibility of the states. The principal preoccupation of leaders in the Victorian medical profession at this time was to establish conditions similar to those they saw overseas, in hospitals, research facilities and medical training, for the development of a reductionist and standardised approach to problems of ill-health in the Victorian community. The designation of the infirm aged as a problem requiring a social solution, not a medical one, meant that the care of this group was located outside the realm of active medical practice, opening up the possibility for it to be included in an emerging field of age-specific welfare.
Making Old Age Public What was meant by the expression ‘old age’ in the early decades of the twentieth century? In Australia the main source of information on this topic is the discussions that attended the introduction of Age Pension legislation, first by Victoria and New South Wales around 1900, and then
32 in 1909 by the newly installed Commonwealth.2 This legislation marked the first formal acknowledgment of old age in the life of the young Australian nation, and in that sense, the public history of old age in this country begins with an administrative measure to relieve poverty. In his account of the Age Pension legislation, T. H. Kewley notes that when the bill was presented to the Commonwealth parliament, no reason was given why the age of eligibility was set at 65 years (with the proviso that when funds permitted women would qualify at the age of 60). In a report on social insurance in 1910, George Knibbs, the Commonwealth Statistician, noted in passing that the choice of age of eligibility was an arbitrary one.3 From the last decade in the nineteenth century, the proportion of people in Victoria over the age of 65 years had begun to resemble that in countries such as Great Britain and the United States, that is between four and five per cent of the overall population.4 Unlike these other countries, this group in Victoria in the 1890s, consisted mainly of men due to their predominance amongst the immigrants attracted by the discovery of gold. It was not until well into the twentieth century that the numbers of women exceeded men.5
Knibbs’ comment suggests that Australian legislators did not go to the lengths their English counterparts did when the Age Pension was introduced there in 1908. The committee that drafted the English legislation sought advice on the question of age of eligibility from a range of sources in the trade unions, occupational pension schemes and poor relief organisations. Jill Roebuck concludes that the age of 70 was accepted as the beginning of old age on the basis of combining a broad common understanding about the capacity of men and women to work after the age of 60, with a pragmatic regard to the increased costs associated with accepting a lower age of eligibility.6 Kewley notes that
2 In comparison with the constitutions governing other federal states, the Constitution of the Commonwealth of Australia was unique in establishing assistance for the aged as a statutory right through the Invalid and Old-Age Pensions Act 1908. In the United States for example, this was not achieved until the 1930s, P. Gunn, ‘Legislating Filial Piety: The Australian Experience’, Ageing and Society, vol 6, June, 1986. p.136-137. 3 Kewley, op. cit; p.74-75, J. Dixon, Australia’s Policy Towards the Aged: 1890-1972, Canberra College of Advanced Education, Canberra, 1977, p.27. 4 Davison, op. cit. p.43-44. 5 Dixon, op. cit, Table 1.1, p.2. 6 J. Roebuck, ‘When Does Old Age Begin? The Evolution of the English Definition’, Journal of Social History, 12, no 3, 1979, pp.416-428. Roebuck outlines a range of community understandings of old age, which were expressed in schemes for the relief of
33 concern with cost certainly prevented an age of eligibility lower than 65 being adopted by Australian legislators.
There are no indications that these legislators were aware of a new form of common understanding about old age, the ‘scientific’ truth of old age which Henning Kirk maintains informed the deliberations of Continental legislators regarding age of eligibility.7 Kirk accords Adolphe Quetelet the honour of inventing the category of ‘the elderly’ defined by age. Quetelet, was a Belgian astronomer and mathematician who wanted to develop a ‘social physics’ by applying statistical methods to human life. He derived his definition from statistical observations relating to diminishing body mass and height after the age of 50, combined with the further observation that the survival curve declined significantly between the 60th and the 65th year of life.8 Kirk suggests that Quetelet’s definition, together with the view of ageing which emerged in French and German medical circles in the late nineteenth century based on the sciences of biology and chemistry, was absorbed into popular health literature, encyclopaedias and dictionaries to provide the basis of a new ‘scientific’ common understanding which influenced Continental legislators.9 There is, however, no evidence in the secondary sources that either English or
poverty and occupational pensions. An estimation of the capacity to work was common to them all, pp.417-419. In older societies in England and Europe, there was also a tendency to associate old age with the ages around 60 to 70 years, and the advent of old age was marked by diminished responsibilities and expectations of what an individual would contribute to the social life of the community, S. Shahar, ‘Old Age in the High and Late Middle Ages’, in Old Age from Antiquity to Post-Modernity, eds P. Johnson & P. Thane, Routledge, London, 1998. 7 Kirk, op. cit. p.489-490. The influence of European thinking about the role of the state in the health of the nation was more explicit in the ideas of J. H. L. Cumpston and J. S. C. Elkington, two advocates for the establishment of the Commonwealth Department of Health in the period following the end of the First World War, M. Roe, ‘The Establishment of the Australian Department of Health: Its Background and Significance’, Historical Studies, vol 17, no 67, 1976, p.182 and pp.183-188. Both men spent time in England and Europe around the turn of the century where their plans for public health in Australia were shaped by ideas that linked disease to conditions of work, housing and poverty, M. Roe, Nine Australian Progressives, Vitalism in Bourgeois Social Thought, 1890-1960, University of Queensland Press, Queensland, 1984, p.92 in regard to Elkington and p.119 regarding Cumpston. For further discussion see chapter two. 8 Ian Hacking describes Quetelet (1796-1874), as a man fond of numbers and happy to jump to conclusions, who enthusiastically applied the methods of statistics to the interpretation of human social life in a project aimed at laying the groundwork for a ‘social physics’ for the management of populations, I. Hacking, The Taming of Chance, Cambridge University Press, Cambridge, 1990, p.105. 9 Kirk, op. cit. pp.492-495.
34 Australian legislators were influenced in their thinking by a rationalised European categorisation of old age.10
The everyday experience of legislators may have led them to associate the age of 65 with diminished physical strength. Unless they were lucky in entrepreneurial ventures, most men and women made their place in colonial society by dint of unremitting hard labour which took an inevitable toll on their bodies. The effect of hard work was exacerbated by poor nutrition and, for many, by the peripatetic way of life imposed by the pursuit of success and security. Even in their fifties many people looked old. Some men may then have had to face the added burden of unemployment, or lower wages than younger adults, because employers were ready to conclude that age impaired productive capacity. In the factories that sprang up in the inner suburbs of Melbourne an older man might take home one fiftieth of the wage due to him according to Wages Board prescribed rates. For women the labour associated with childbirth and child rearing added to the toll on their physical resources.11 The opening pages of The Fortunes of Richard Mahony, set in the central Victorian goldfields in mid nineteenth century, give a preview of the men whose difficulties in competing with younger men for scarce work in the depression of the 1890s led to the introduction of the Age Pension in Victoria. Life on the diggings ensured that young bodies aged quickly. Working for days up to their waists in water, miners’ bodies were attacked by ‘dysentery in the hot season and winter cramps’. Joints became knotted and knarled with rheumatism and in time, drink taken to blunt the effects
10 The only direct association made between the Australian scheme and European models was made by L. Tierney in ‘The Pattern of Social Welfare’, in A. F. Davies and S. Encel, eds, Australian Society. A Sociological Introduction, Cheshire, Melbourne, 1967, p.114. Tierney states that the Australian scheme was based on the Danish one but does not give references. His comment was referred to by G. Kaplan, ‘Ageing in Australia’, in Australian Welfare, Historical Sociology, ed R. Kennedy, Macmillan, South Melbourne, 1989. However Kewley, whose account appears to be most comprehensive, does not link the Australian scheme directly to the Danish one. He notes that J.C. Neild compared the New South Wales pension scheme with the Danish model but the model adopted by the Commonwealth appears to have been largely shaped by local influences and the New Zealand scheme. Kewley, op. cit. p.49, p.73. 11 Davison, op. cit. p.45; S. Macintyre, The Oxford History of Australia, vol 4, 1901-1942, The Succeeding Age, Oxford University Press, Melbourne, 1986, pp.31-35; J. McCalman, Struggletown, Public and Private Life in Richmond, 1900-1965, Melbourne University Press, Carlton, Victoria, 1984, pp.29-34; Australia 1888, eds G. Davison, J.W. McCarty, A. McLeary, Fairfax Syme & Weldon Associates, New South Wales, 1987, p.329; J. McCalman, Sex and Suffering, Women’s Health and a Women’s Hospital, Melbourne University Press, Carlton, Victoria, 1998, Chs 1 & 2; J. Godden, ‘A New Look At Pioneer Women’, Hecate, vol v, no 2, 1979, pp.7-21.
35 of exhaustion and disappointment, took its toll also.12 On the land, life was no less exhausting and some colonists made an analogy between pioneering and the trials of warfare - both threatened life and limb and both should be viewed as service to the nation.13
The introduction of the Age Pension provided the occasion for the first public discussion of the place of older adults in the life of the new nation.14 Legislators were responding to the plight of those who were poor, but they appear to have taken the opportunity to locate this measure within a broader public reflection on, and acknowledgment of the meaning of old age in Australian society. This stance may have been prompted by the effects of the economic depression of the 1890s in Victoria, where even the most provident and industrious of citizens were rendered destitute through no fault of their own. Such ill fortune was an affront to the evangelical Protestantism that imbued public life, but the likelihood that a state-funded pension would undermine filial responsibility or encourage fecklessness was just as affronting.15 These sentiments were taken up in Commonwealth legislation to produce a measure which acknowledged an earlier contribution to communal prosperity by these ‘worn-out wealth- creating human machines’, but which also, through its conditions of
12 H. H. Richardson, The Fortunes of Richard Mahony, Penguin Books, Ringwood, Victoria, 1982, p.12. 13 Davison, 1995, op. cit. p.52. 14 Australia was unusual in that the Age Pension was the first official recognition of ‘service to the state’ by any section of the population. In other countries pensions for war veterans and public officials preceded old age pensions. Quadagno states that in the United States for example, enthusiasm for providing age pensions was constrained by the patronage system, which had grown up around war veterans’ pensions, J. S. Quadagno, ‘The Transformation of Old Age Security’, in Old Age in a Bureaucratic Society, eds D. Van Tassel & P. N. Stearns, Greenwood Press, New York, 1986, p.138-139. Theda Skocpol, in a more extensive examination of the state funded benefits for Civil War veterans, concludes that within the structure of the nineteenth century US state, patronage certainly needs to be taken into account but there was another dimension. The opposition to publicly funded welfare programs such as those introduced in Europe and Australia and New Zealand at the turn of the century, was just as strong amongst those who advocated benefits for veterans as it was in later generations. Veterans benefits were made available to those who had ‘earned aid’ through service to the nation, Civil War pensions ‘privileged both the political party and those among the citizenry who had participated victoriously in a morally fundamental moment of national preservation’, T. Skocpol, Protecting Soldiers and Mothers, The Political Origins of Social Policy in the United States, The Belknap Press of Harvard University Press, Cambridge, Massachusetts, 1992, Chapter2. 15 Gunn, op. cit. argues that although separate states enacted legislation to compel families to provide for their needy relatives, it was directed more towards the needs of deserted mothers and their children than the aged, and was rarely enforced. Despite the emphasis in pension legislation on filial responsibility, the state had already accepted responsibility for the destitute, particularly in Victoria, by heavily subsidising the benevolent societies in their work.
36 eligibility, ensured that need had to be fully justified.16 The ethos of individualism and respectability was thus preserved; demonstrating to the better off that those in need had indeed acted responsibly. The Age Pension was to be granted as a right, not a charity, and it was not considered that it should furnish the whole of any individual’s income. It was to be ‘something in the nature of a retiring allowance’ available to the ‘deserving poor’.17
The alacrity with which legislators in both state and Commonwealth parliaments enacted proposals for an Age Pension may have reflected genuine communal acceptance of responsibility for its aged citizens.18 Individuals from all sides of politics supported the measure in sentiments suggesting that it was indeed prompted by some sense of collective responsibility to those who had contributed towards the collective well- being. The introduction of the Age Pension provides an apt example of the analogy Stuart Macintyre made between the early years of self- government in the Australian states and the Sunday School Superintendent at the annual picnic who, in times of relative plenty, ensured that amongst the activities of settlement, there were ‘prizes for everyone’.19 Although the Age Pension was formally acknowledged as a right and not a charity, the notion of deservingness, associated with charity, persisted in a form peculiar to the culture of the new nation. The generosity of spirit and the desire to acknowledge a responsibility to every ‘single unit’ within the nation sat uneasily with the ethos of possessive individualism that underpinned national life, in which a plea for public assistance was associated with moral weakness. This first public acknowledgment of old age as a stage in the life of Australian men and women was, however, an
16 Kewley, op. cit. p.76-77; Dixon, op. cit. p.22, pp.27-31. Applicants put their claim to the Registrar of Pensions for their district who examined it before passing it on to a magistrate who could call upon the applicant to support the claim. 17 Kewley, op. cit. p.81-83, Commonwealth legislation reflected the sentiments expressed in earlier state legislation in Victoria and New South Wales as well as that enacted in New Zealand where a similarly uneasy recognition existed that the principles of self help, family obligation and Christian charity did not suffice to address the needs of destitute old people, D. Thomson, ‘Old Age in the New World: New Zealand’s Colonial Welfare Experiment’, in Old Age from Antiquity to Post-Modernity, op. cit. 18 A non-contributory scheme assured the equal treatment of men and women. Where pension schemes were tied to working life, women were not so well off, Thane, 2000, op. cit. pp. 330-332 19 Macintryre, op.cit. p.100.
37 aside, and perhaps even a somewhat absentminded one, to the more pressing business of building a new nation.20
The Public Meaning of Old Age In this first official demarcation of old age, the condition was characterised as a period of physical decline, beginning at the ages of 65 for men and 60 for women. The conditions of eligibility for the Age Pension ensured that ‘the aged’ were those who were of good character, had resided in Australia for 25 years and were of acceptable racial origins.21 The means test ensured it was also a period, particularly for men, of exclusion from one of the principal activities of citizenship – productive activity. At worst it could be seen as an indication of failure in the civic enterprise of providing a respectable degree of self-support. Macintyre has included the Age Pension amongst the measures that were aimed at reconciling the working class to the social order of industrial capitalism in the early years of the twentieth century. The working man was guaranteed a ‘living’ family wage, with assistance in the form of free education and maternity allowances to foster the development of the coming generation, and the age pension to cushion the effects of exclusion from an increasingly uniform and regulated workforce.22 At the same time, the acceptance on the part of the Commonwealth government of such an open–ended
20 P. D. Phillips, ‘Federalism and the Provision of Social Services’, in Social Policy in Australia, ed J. Roe, Cassell, Australia, 1976, p.256. Phillips concludes it is likely this aspect of welfare was assigned to the Commonwealth government without much consideration of what was entailed. The Commonwealth funded pensions from a trust fund established for the purpose under the Surplus Revenue Act, 1908, which permitted funds to be set aside and not available for distribution to the States. The Royal Commission on Old Age Pensions, 1905-6, does not appear to have considered the matter of financing Age Pensions in any detail. Two factors may have influenced the Commission’s judgement that conditions in Australia and Germany (the leading example of a contributory pension at the time) were different. First, the measure was intended to address immediate problems of poverty faced by the state governments, particularly Victoria and New South Wales, second, Labor members of parliament were against a contributory scheme because it maintained the distinction between rich and poor, Kewley, op. cit. pp.70-72, p.86-87; Gunn, op. cit, p.154ff; Dixon, op. cit. p.3. 21 The conditions of eligibility in Australia, initially confined the pension to those who passed the means test, who were British subjects (excluding some Aborigines, individuals of Asian ancestry, Pacific Islanders, Africans and New Zealanders), and who had resided in Australia for 25 years. The applicant’s good character was also taken into account and inmates of benevolent asylums, hospitals, goals and insane asylums were excluded, Dixon, op. cit. p.27. 22 Macintyre, op. cit. p.100. In contesting the view that the United States government did virtually nothing about publicly funded welfare until the New Deal period of the 1930s, Skocpol contrasts the paternalism of measures such as the Age Pension in Australia with the development in the US of the foundations for a maternalist welfare system in the period between 1900 and the 1920s. The various social benefits and protective labour regulations that were introduced at this time were a response to the demands of female dominated
38 financial commitment towards one segment of the poor, at a time when its financial resources were uncertain, meant that every year in the budget deliberations the sentimental recognition of the place of the elderly clashed with financial exigency.23 The somewhat grandiose aspiration to recognise the place of the aged in Australian society produced a sacred cow before which all political parties were obliged to bow, but whose worship was constrained by the demands of fiscal responsibility.24
The categorisation of old age through the introduction of the Age Pension suggests that old people were marginalised within the general population of active ‘independent’ working people.25 The process appears to reinforce the ‘ageism’ Graeme Davison has discerned in colonial society where grandparents were a rarity, and the virtues of community life were those ‘of youth - energy, optimism, readiness to experiment, impatience with tradition’.26 Witnesses called to give evidence in coronial inquiries into the deaths of old people by suicide suggested on occasions that the fatal act arose out of shame at having to claim the pension. Although in no instance was it found that this was in fact the case, the comment itself implies there may have been a tendency in general to regard the status of ‘pensioner’ as shameful.27 Nevertheless, the steady rise in numbers drawing the pension in the first twenty years after the 1908 legislation suggests that old people were not reluctant to avail themselves of this
agencies whose objectives were to establish beneficial conditions for women and their children, Skocpol, op. cit. p.253ff, pp.367-372, p.522-523. 23 The unanimity with which this measure was enacted into Federal legislation reflects Rowse’s characterisation of this period of federalism (1906-1916) as one of ‘collective liberalism’ in which both liberals and socialists viewed the state as a neutral instrument to be used through parliamentary representation, T. Rowse, Australian Liberalism and National Character, Kibble Books, Melbourne, 1978, p.40. 24 In his discussion of the National Insurance legislation introduced by the Lyons’ government in 1938, Watts indicates that there may well have been a view within Treasury from the beginning, that the non-contributory character of the Age Pension scheme was ‘morally irresponsible and fiscally unsound’. Concern about funding pensions was central in the fiscal crises faced by Australian governments from the 1920s up to the Second World War, R. Watts, Foundations of the National Welfare State, Allen & Unwin, Sydney, 1987, pp.8-15. 25 The expression ‘old people’ is used throughout this thesis as it is used during the period under discussion. The same approach is taken to the term ‘inmates’ as it was used to refer to the individuals cared for in the benevolent institutions. 26 Davison, 1995, op. cit. p.41-42. The rarity of grandparents is questioned by Dawn Peel on the basis of a small study of 286 adults who lived in the area that was to become the Shire of Colac, in 1857, and who lived or retained their links with the district until their final years, Peel, op. cit. p.269. 27 S. Cooke, ‘’Terminal Old Age’: Ageing and Suicide in Victoria, 1841-1921’, in Ageing, Australian Cultural History no 14, 1995, p.84-85.
39 benefit.28 This impression is reinforced by the numerous alterations to the eligibility conditions in subsequent years that, although not far-reaching in scope, do indicate a legislative response to community demand.
As Pat Thane points out in her recent history of old age in England, the introduction of the Age Pension there meant the most impoverished were relieved of the degrading business of scrabbling around for a meagre living.29 Claiming the pension may have been an affront to respectability that some found hard to stomach, but it was less of an affront than the degrading poverty that was the only alternative. The value of the Age Pension in enabling the elderly poor to continue to play some part in the everyday life of their communities should not be underestimated.30 Regardless of how elderly Australians regarded the Age Pension, it is more likely that in this process of defining old age we have a definition of the elderly poor rather than a reliable guide to the meaning of old age per se. A passing comment by fifty-five years old Frederic Eggleston, a Deakinite Liberal and social critic, to the effect that Australian institutions in the early 1930s were dominated by old men, suggests that in the early decades of the twentieth century, ‘old age’ was defined in very different ways at different levels of Australian society.31
In her essay on the place of old people in the everyday life of the Rocks area of Sydney in the 1820s, Grace Karskens suggests that an assessment of age was based more on appearance and capacity than actual years, thus was more likely to be a distinguishing mark of the poor than the wealthy. Those who survived into old age, which may have been any time from the age of 50 onwards, lived in much the same fashion as they had in earlier years. Men and women continued working and marrying, perhaps for the second or third time, and conducted business. They were lampooned when they acted in a fashion considered more appropriate to younger ages - women whose choice of dress was regarded as more suited to younger
28 Kewley, op. cit. Table 3, p134 shows that in 1912, 17.3 per cent of the Australian population were receiving the Age Pension. In 1939, the percentage was 33.5. 29 Thane, 2000, op. cit, p.227-228. 30 During worst of the Depression, pensioners in the working class suburb of Richmond were the mainstays of the local economy because they had regular income, McCalman, 1984, op. cit, p.197. 31 W. G. Osmond, Frederic Eggleston, An Intellectual in Australian Politics, Allen & Unwin, Sydney, 1985, p.158. Eggleston’s remark is quoted by G. Bolton, The Oxford
40 bodies and men who showed an interest in carousing and sex - but ageism was always tempered by respect for rank.32 It is not unreasonable to conclude that similar attitudes prevailed in the early decades of the twentieth century.33
The introduction of the Age Pension gave a clearer definition of old age as a stage of life than in the earlier period described by Karskens although it was, at the time, as much a definition of poverty as old age. It set a precedent for separating out the needs of older Australians from those of the poor and dependent in general, one that led to the ‘aged’ being seen as a special object of social and political attention in the following decades, an unassailable verity of social and political life. The response of medical practitioners to the dependent and infirm aged was also shaped within this cultural mind-set which found further scope for age-related welfare measures in the postwar prosperity of the 1950s and 1960s. Measures that began to shape the experience of old age, not just for the poor, but for all classes except the very rich.
Old Age in Medical Work Up to the 1940s at least, there are few signs that older adults constituted a special category of patient for doctors in Victoria, or elsewhere in Australia, and yet many doctors would have found a substantial number of their patients amongst this group.34 Well into the 1950s most doctors in Victoria, like their colleagues in the other states, worked in general practice so older adults would have been included amongst their fee- paying patients. Older adults also belonged to the various Friendly Societies established by working people to provide insurance against
History of Australia, Vol 5, 1942-1988, The Middle Way, Oxford University Press, Melbourne, 1990, p.5. 32 G. Karskens, ‘Declining Life: On the Rocks in Early Sydney’, in Ageing, Australian Cultural History, 1995, pp.65-66. 33 A. Hartshorn, ‘The Presentation of Old Age in Selected Twentieth Century Australian Novels’, Masters Thesis, University of Queensland, 1993, Hartshorn examined selected novels in order to understand attitudes to old age in Australia in the twentieth century on the reasonable assumption that novelists’ characters reflect community views of their time. Her conclusion is similar to Karskens; older adults were respected while they were protected by wealth and social institutions. Those who were poor, decrepit and isolated were not. 34Pensabene, op. cit. Table 4.10, Doctor-Population Ratios, Victoria, 1871-1933, p.74-81. In the relatively young population of early to mid nineteenth century Australia, the degenerative diseases of old age were not prominent in medical work except as they were related to alcohol and syphilis. This situation changed from the turn of the century when the sicknesses of a growing population of older adults became more prominent, B. Gandevia, ‘A History of General Practice in Australia’, MJA, vol 2, 1972, p.382.
41 sickness and unemployment.35 Medical practitioners contracted with the Societies to provide services to members on a capitation. Although, from the inter-war period, there was growing discontent amongst the medical profession about their relationship with the Societies, Lodge practice provided a level of income for doctors in industrial areas that was often not possible in more affluent suburbs where there was more competition for fee-paying patients. Also Lodge practice provided medical services to the working class that were otherwise not affordable.36 The doctors who provided honorary services in the large metropolitan hospitals would also have treated the poor aged in the course of treating the poor in general, for whom the outpatient departments in these hospitals provided means–tested medical services.37
The only doctors whose work did focus on illness in the aged were the few employed as medical officers in one of the several benevolent asylums in the state.38 These institutions were established in the period between the late 1840s and the 1860s, by charitably minded citizens of Melbourne, and the provincial cities that grew up on the goldfields. The asylums were part of a complex network of indoor and outdoor relief, provided under the direction of voluntary committees of management, funded initially by public subscription, but ultimately receiving the bulk of their funding from the state government.39 They offered refuge to all age groups but while younger adults were able to move on when times improved, those who were older and infirm had little choice but to remain there. The assistance provided to the elderly was prompted by sentiments similar to those expressed in discussions attending the introduction of the Age Pension: The Melbourne Benevolent Asylum succours those who have failed in the effort to help themselves while helping onwards, by their
35 D. G. Green & I. G. Cromwell, Mutual Aid or Welfare State, Australia’s Friendly Societies, George Allen & Unwin, Sydney, 1983, p.139-149. 36Gillespie, op. cit. pp.7-11. 37 Pensabene, op. cit, p164, Tables 10.1, 10.2. 38 The Melbourne Benevolent Asylum, located in North Melbourne (moved to Cheltenham in 1911 because of lack of space), the Immigrants Aid Society Home in St Kilda Rd which moved to Royal Park around the same time (after several changes the institution was named Mount Royal Home and Hospital for the Aged), and the large asylums in the goldfields cities of Ballarat, Bendigo, Castlemaine and Beechworth, R. A. Cage, Poverty Abounding, Charity Aplenty, The Charity Network in Colonial Victoria, Hale & Iremonger, Sydney, 1992, Ch 6; B. Dickey, ‘Health and the State in Australia 1788-1977’, Journal of Australian Studies, no 2, Nov, 1977, p.54-55. More detail on the benevolent institutions will be found in chapter two. 39Cage, op. cit. p.21.
42 labours the progress of the Colony of Victoria … That they have broken down in the battle is their misfortune, and it is now for the more fortunate to help those whom old age and sickness prevent from any longer helping themselves and us.40
The benevolent asylums were obliged as a condition of their operation to provide medical care, and doctors were employed as either visiting or resident medical officers.41 Some of these practitioners were motivated by the same sense of Christian duty which inspired the institutional enterprise, and some conscientiously made the best of the opportunities they found there because other avenues of medical work were closed to them. Others, less committed to either Christian values or professional duty, used these positions as casual stopgaps while they found more congenial work.42 In the period from the late 1890s to the early 1950s, when doctors had to rely on their own entrepreneurial efforts to make a living in competition with their colleagues, especially in the metropolitan area, work in the benevolent institutions had its place, albeit not the most prestigious, within medical practice in Victoria.
The medical practitioners who cared for the inmates of the benevolent asylums do not appear to have written about their work. If the professional journals of the late nineteenth and early twentieth century are any guide, the medical care of the aged, and the broader question of longevity, that attracted the attention of doctors in the northern hemisphere at this time appears to have raised little interest amongst Australian doctors.43 If some ageing Australians and their medical attendants were interested in the range of rejuvenatory measures publicised at this time their interest was not aired in the Australasian Medical Gazette or its
40Quoted in M. Kehoe, The Melbourne Benevolent Asylum, The Annals of Hotham, vol 1, Hotham History Project, Melbourne, 1998, p.16. 41 For example see, Kehoe, op. cit. p.16 and J. Uhl, Mount Royal, A Social History, Mount Royal, Hospital, Parkville, 1981, p.5-6. The Melbourne Benevolent Asylum, located nearby the Melbourne Hospital, also had the benefit of the attention of Melbourne’s most prominent medical practitioners in an honorary capacity. Kehoe notes that in 1868 this institution had a reputation for the quality of care provided there, including medical attention, p.24, p.32. 42 Uhl, op. cit. p.78ff and p.85ff; Kehoe, op. cit. p.51-52. 43 The material that may have been available at the turn of the century to Victorian doctors interested in questions relating to the medical care of old people and longevity is described in Grmek, op. cit who provides a succinct account of how doctors from antiquity to the twentieth century, have though about health and illness in old age. See also G. Gruman ‘A
43 successor, The Medical Journal of Australia.44 The doctors employed to oversee the care of poor, infirm old people were preoccupied with ensuring that committees of management provided adequate food, living conditions that did not endanger the health of their charges, and an environment in which those who required nursing care could be suitably accommodated.45 In the same spirit of benevolence that Australians acknowledged the needs of the aged poor through the Age Pension, medical practitioners joined their committees of management in providing care for the aged and infirm. It was, however medical care for the poor aged, not the aged in general.
At no time did they have the resources available to those French physicians who, by mid-nineteenth century, had ‘formulated a definition of old age that separated it medically from all other age groups and required the physician’s complete attention’.46 Much of this work was done at the Salpêtrière in Paris where Jean-Martin Charcot was appointed chief of medicine in 1862. Under his supervision the institution, funded directly by the state and at the height of its fame in the 1880s, had been transformed from ‘an establishment known for its riots, plagues and exorbitant mortality rates to one recognised for its laboratories, lecture halls, and licensed practitioners.’47 The only connection the benevolent asylums had at this time with the post-mortem work that provided the basis of the French physiological and anatomical model of old age was to supply the unclaimed bodies of deceased inmates to the anatomy department in the medical school at the University of Melbourne.48
History of Ideas About the Prolongation of Life’, Transactions of the American Philosophical Society, vol 56, no 9, 1966. 44 For example Brown-Sequard’s experiments with injections of animal testicles or Metchnikoff’s phagocytic theory of cellular rejuvenation and others, Grmek, op. cit. pp.47- 49 and for a more detailed exposition of Metchnikoff’s ideas which were popular in America, W. A. Achenbaum, Crossing the Frontiers, Gerontology Emerges as a Science, Cambridge University Press, Cambridge, 1995, pp.25-23. 45 Kehoe, op. cit. p.60; Uhl, op. cit. p.85ff. 46 Carole Haber points out that this model was a by-product of the development of a conception of disease in terms of changes in tissues and cells which emerged in the Paris hospitals in the early nineteenth century. By mid-century ‘at least fifteen French physicians had published monographs on the unique character of the elderly’, Haber, 1983, op. cit. p.58. 47 M. S. Micale, ‘The Salpêtrière in the Age of Charcot: An Institutional Perspective on Medical History in the Late Nineteenth Century’, Journal of Contemporary History, vol 20, 1985, p.722. 48 Uhl, op. cit. p.113-114.
44 The model of old age developed in the French hospitals, represented in general histories of geriatrics as the intellectual basis of the specialty, was based on pathological changes in bodily structure and function in the aged body.49 Similar changes had been described before, but from a point of view that did not align age-related changes with changes in the individual’s constitution and susceptibility to disease. In the French model age-related changes were seen as changes in the composition of the body, indistinguishable from the changes in composition due to disease. From this point of view all physiological and anatomical changes were pathological and the ageing process itself appeared as an inevitable deterioration of the ‘fundamental elements of existence’. Medical care of the aged, from this standpoint, presented such difficulties in pathology that it required special study and long experience.50 Such intensive attention however, was not accompanied by any therapeutic possibilities. In addition, the inherent pessimism in this conception of the aged individual was compounded by its derivation from observations of individuals in public institutions, who, by virtue of their situation, may be described as having been overcome, physically and mentally, by the vicissitudes of life in general, not just the experience of growing old.51
Doctors in Victoria did not follow the French lead, and their reluctance to do so was not unique. Carole Haber suggests that English and American doctors were, by training and experience, disinclined to adopt the model developed in the Paris hospitals.52 The medical profession in Victoria developed as an off-shoot of the British profession, and until the early 1960s, continued as part of the professional organisation of British doctors, as a branch of the British Medical Association, so it may be assumed that a similar point of view prevailed there.53 From the Anglo-
49 Haber, 1983, op. cit.; Grmek, op. cit. 50 Haber, 1983, op. cit. pp.57-63. 51 Micale, op. cit. p.711-713; P. Stearns, ‘Geriatrics’, in Old Age in European Society, The Case of France, Holmes & Meier, New York, 1976, p.85 52 Haber, 1983. op. cit. p.68. 53 British medical training dominated the medical profession in Victoria. First, through the immigrant doctors who came to the colony, and then later as local students elected to train in the British system rather than in the more expensive and longer course offered by the medical school at the University of Melbourne. Doctors continued to go to Britain for postgraduate training until after the Second World War, Pensabene, op. cit. p64-68. Despite the close ties with the British medical profession, Gandevia notes that doctors in Australia did develop a very different type of practice, one characterised by individuality, competence in a great variety of situations, and a relatively high social standing, Gandevia, op. cit. p.381-382.
45 American perspective, debility was also acknowledged as a consequence of long life, but with the additional insight that the effects of ageing could be ameliorated by the adoption of a regimen of daily life in which anything that might overtax the body was avoided. The point at which an individual needed to pay attention to these matters was identified as the climacteric, a critical age or period in life for both men and women when special changes occur.54
Phillip Muskett, a Sydney doctor whose interest in instructing the Australian public in the art of preserving good health by means of diet marked him as somewhat eccentric at the time, defined the climacteric as the point where involution set in. By involution he meant the ‘shrinking or withering of the tissues of the body, accompanied by a degeneration or deterioration of their structure’.55 For women the climacteric took place around the age of 55 and for men, around 60 to 65. In an earlier text, The Art of Living in Australia, he outlined a daily routine for the elderly which he believed would diminish the effects of the ageing process.56 The notion of the climacteric appears to maintain the same association between old age and inevitable decay as does the French model. However, where the French physicians left little or no room for the possibility that the effects of ageing could be modified by constitutional or social factors and, into the bargain, presented the medical care of old people as a complex and esoteric skill, the Anglo-American approach had the potential to be more pragmatically optimistic.
The more optimistic view taken by Australian doctors is conveyed by the response to a remark made in the course of a lecture by Sir William Osler in the United States in 1905.57 Osler referred to a ‘fixed period’ of life when men were at the height of their powers, a period that came to an end at the age of 60. At this point he said, having achieved all they were likely to, they should be chloroformed.58 An anonymous commentator in the
54 Haber, 1983, op. cit. p.69-72. 55 P.E. Muskett, The Attainment of Health and the Treatment of the Different Diseases By Means of Diet, 2nd. edn, William Brooks & Co. Ltd, Sydney, 1909, p.487ff. 56 P.E. Muskett, The Art of Living in Australia, Eyre & Spottiswoode, London, nd, (Preface is dated 1893). 57Cole, op. cit. p.170. Sir William Osler gave this lecture on the occasion of his retirement from the medical faculty at the Johns Hopkins University Medical School at the age of 56. 58 Cole, ibid. pp.162-174, In referring to the ‘fixed period’ Osler was drawing on a notion current in the last quarter of the nineteenth century, particularly in America, developed by
46 Australasian Medical Gazette, taking Osler’s remark seriously, rejected it and in doing so assembled other authorities to justify his contention that a regimen of moderation would help ensure an active and prolonged old age despite the burden of genetic inheritance and the trials of modern life.59
In view of the tendency amongst Australian doctors to see health and sickness in old age as simply an aspect of everyday medical work, it is not surprising that the first text in which it was presented as a specialist field was not even reviewed in the Medical Journal of Australia. I. L. Nascher’s text, Geriatrics: The Diseases of Old Age and Their Treatment, Including Physiological Old Age, Home and Institutional Care, and Medico-Legal Relations, was published in 1914. Nascher, an American physician, coined the word ‘geriatrics’ to describe the special field of the medical care of the aged.60 He combined the anatomical and physiological investigations of the French and German physicians and the empirical studies of the British and Americans to develop an approach to health and sickness in old age which emphasised two principles. The first was that just as there is a normal physiological condition of childhood, so there is for old age; disease in old age therefore should be seen as a pathological state occurring in a normally degenerating body, not disease as it occurs in maturity. From this point of view treatment would be aimed at restoring a diseased organ or tissue to the state normal in senility, not the state normal to maturity.61 The second principle was that social factors, that could be ignored with impunity when treating younger adults, were of primary importance in the aged. In this respect Nascher’s call for medical attention to the sick aged also included a call for the provision of welfare measures, because in bodies weakened by advanced age, they played an important
the physician George Miller Beard. It was satirised in a work of Anthony Trollope with the title, The Fixed Period. Cole notes that there is good reason to believe Osler may not have intended his remark to be taken as seriously as it was throughout the English-speaking world. 59 Editorial, ‘The Prolongation of Life’, Australasian Medical Gazette, August, 1906, p.403-4. 60 This description of Nascher’s approach is taken from the Introduction to The Care of the Aged (Geriatrics) 5th edn, The C. V. Mosby Company, St Louis, 1946, written by Nascher’s disciple, Malford Thewlis. Thewlis took over the task of publicising geriatrics from Nascher and his text is intended to follow on from Nascher’s. 61 Nascher seems to use the term senility here in its pre-nineteenth century meaning, that is anything suited to old age. By the end of that century the term was generally used to describe age-related ailments. To become senile was to advance into a state of debilitating illness. Haber, 1983, op. cit. p.74.
47 part in determining whether a patient recovered from an episode of sickness or deteriorated further.
Nascher defined ‘geriatrics’ as a specific sphere of medical work that required specialist knowledge in order to distinguish the pathological changes of ageing from those that were normal, together with the clinical judgement that came with wide experience and a sympathetic approach to elderly patients.62 The presentation of his case may have done little to stimulate conscientious Victorian doctors with an interest in this topic. These practitioners would already take this approach with their elderly patients, especially when they were private patients able to pay for the doctor’s time. Despite lacking the finer details of the physiological changes exposed by laboratory investigation, experience and familiarity with their patients would provide the basis for deciding whether any alteration in a patient’s condition was pathological or not, and it would also govern any assessment of likelihood of recovery from an episode of illness. Patients who could afford to pay the doctor’s fee were also likely to have to the social support necessary to facilitate recovery. In the asylums, doctors already cared for individuals who lacked the social and financial resources that may have diminished the onset and extent of debility. An indication that medical work in the asylum was considered as somehow separate and different from general practice may be found in the 1933 review of F.M. Lipscomb’s Diseases of Old Age, which the reviewer recommended ‘for doctors taking appointments in hospitals for the aged’, not for general medical practice.63
Nascher’s notion of geriatrics, like that of the French and German physicians who inspired him, was derived from his experience with institutionalised and impoverished old people. His point that the diseases and infirmities of old people should not be attributed to old age and left untreated, was perhaps as much a comment on current medical practices in relation to the care of poor old people, as the grounds on which a specialist field could be built. This connection between geriatrics and poverty persisted as English and Scottish doctors further developed the field in the
62 Thewlis, op. cit. Introduction. Grmek, op. cit, notes that in the early twentieth century the medicine of old age was most developed in Germany, Austria and France, but within the framework of internal medicine, not as a speciality, p.69-72. 63 MJA, vol 2, 1933, p.316.
48 1940s and 1950s, and it was to be an integral aspect of the establishment of geriatrics in Victoria. However in the early decades of the twentieth century in Victoria there was no impetus, from either within the medical profession or outside it, to transform the medical care of indigent and infirm old people from a charitable venture into a specific medical enterprise. Even in the United States Nascher’s call to the medical profession to establish geriatrics as a specialty along lines similar to paediatrics received little response.64 In Australia, medical attention centred instead on the marvellous potential opened up in the 1890s by advances in surgery and microbiology that were seen as signalling the beginning of a ‘golden age’ of technical advancement. In this climate of innovation and apparently unlimited promise, Nascher’s call for doctors to pay more attention to failing old people fell on deaf ears.65
Old Age and a Technical, Laboratory-Based Medical Paradigm There are indeed indications from the late 1920s on that such optimism may have been justified. The technical capacity of surgery and the development of specific therapies was slowly beginning to alter the experience of illness for elderly people although it wasn’t until the 1950s that arteriosclerosis, the most ‘formidable’ cause of death and disability associated with growing old, began slowly to succumb to medical science.66 Nevertheless, the science of endocrinology had begun to provide the basis for more sophisticated management of diabetes, and treatment of fractures in the neck of the femur, a common affliction of the elderly, began to be refined to the extent that immobilisation was required
64 Haber comments that despite Nascher’s hopes for the development of geriatrics as a specialist field of practice, he had to admit it did not exactly parallel paediatrics. ‘For children, the standards of health could be clearly charted as they gained strength and intelligence; for the old, the standards of health implied progressive and incurable ailments. The increasing debility of the elderly followed a course that led naturally to death.’ C. Haber, 1986, op. cit. p.77. 65 Pensabene, op. cit. p.33ff, quotes a local practitioner who described the period between 1870 and 1930 as ‘the ‘Golden Age of Medicine’; Earle Page, surgeon and, as leader of the Country Party, architect of the national health service introduced by the Liberal-Country Party coalition in the early 1950s, considered himself fortunate to do his medical training during the decade from 1890 to 1900 when these changes were most exciting, Sir Earle Page, Truant Surgeon ed A. Mozley, Angus and Robertson, Sydney, 1963, pp.17-19. 66 R. Reader, ‘Heart Disease in Australia, 1960-1980, The National Heart Foundation’, MJA, vol 1, 1979, pp.323-328.
49 for less time, thus reducing the potential for sepsis and pneumonia.67 The latter were in turn rendered less deadly with the advent of antibiotic agents after World War Two. Even in the 1920s, in the unsophisticated conditions of a country hospital, skill and technique could bring gratifying results. David Browne, a general practitioner in Western Victoria, drew on his experience at the Alfred Hospital in Melbourne when a family brought their elderly mother to the local hospital after she had already spent many weeks immobile on her back with a fractured leg in splints.68 The old lady was very weak; she had fallen while away from home, and her family had brought her back to die, a justifiable expectation in view of her 84 years. Having located the fracture, Browne instructed her carpenter son in constructing an apparatus to suspend the leg in a sling to maintain the broken ends in apposition and yet permit the patient to sit up comfortably in bed and eat and drink with some enjoyment: Our old ‘battleaxe’ as she was sometimes affectionately called, rapidly improved in health and strength. The bedsores that afflicted her previously healed up and the broken bone began to heal. She went from strength to strength and was finally able to go home using one walking stick only, as she had done before the accident ... (and went on to die at the age of 97).69
The inclusion of a special session on the medical care of the aged, in the deliberations of the Australasian Medical Congress in Melbourne in 1952 illustrates the extent of the changes that took place during the 1930s and 1940s in ordinary medical practice in relation to old people.70 This was the first occasion on which sickness in old age was given such attention at the Congress which had met, intermittently, since the 1880s.71 A
67 F. I. R. Martin, A History of Diabetes in Australia, Miranova Publishers, Camberwell, Australia, 1998; MJA, vol 1, 1934, pp.518-520, vol 1, 1936, pp.743-747, vol 2, 1935, pp.521-523; vol 1, 1936, pp.187-197. 68 A. Mitchell, The Hospital South of the Yarra, A History of the Alfred Hospital Melbourne from Foundation to the Nineteen-forties, Alfred Hospital, Melbourne, 1977, note 275 for details of Ian Hamilton Russell, Browne’s teacher in this field. He was, it appears, renowned for his skill in identifying fractures without the benefit of X-ray and for the techniques he developed for maintaining a broken limb in position, minimising the chances of malformation during healing. 69 D. D. Browne, The Wind and the Book, Memoirs of a Country Doctor, Melbourne University Press, Melbourne, 1976, p.26. 70 MJA, vol 2, 1952, pp.489-492. 71 The first of such meetings, the Intercolonial Medical Congress, was held in 1886. The reason for convening these meetings was to replicate in the southern hemisphere, the ‘great international congresses’ that were held in Europe and the meetings continued every second or third year until the early 1920s. At this point the federal committee of the British
50 physician from Hobart began his discussion of the treatment of cardio- vascular disease in elderly patients, by noting that three-quarters of the beds under his supervision in the Royal Hobart Hospital were occupied by adults between the ages of 65 and 85 years.72 The situation in the general hospitals in Melbourne was certainly comparable.73 His main point was that chronological age was not a good indication of an individual’s physiological state; in cases of cardiac failure, coronary occlusion and cerebro-vascular thrombosis, an accurate diagnosis should always be made. If a problem could be clearly identified it could often be successfully treated. Other speakers made a similar point in relation to anaesthesia and surgery in old people. Careful consideration of the individual often made it possible to undertake successful surgical intervention regardless of chronological age.74
The comments made at this Congress session suggest that it was not so much that doctors were gaining in understanding of the ageing body, but that in dealing with growing numbers of patients who were over the age of 65 years, they enlarged their experience in applying the standard model of disease to elderly adults. It was because doctors conceived of disease as a specific, localised entity, recognisable in clearly delineated clinical pictures, that they were able to apply intensive attention to certain circumscribed problem areas. It was, in a sense, accidental that that these just happened to include problems commonly found in ageing individuals. The growing number of specialist practitioners in Australian medical practice were interested in ordinary disease manifested in older adults. They were not interested in ageing as a process or in specific diseases of old age. In refining their skills in treating older adults, doctors identified aspects of technique that needed to be taken into account in particular
Medical Association in Australia agreed that the Association would, in future, sponsor the meetings and the first session under this new regime took place in 1923. Admission to the Congress was conditional upon membership of the BMA or sponsorship by a member. The new organisation was viewed as having a ‘strictly scientific’ purpose, medico-political interests were left in the hands of the federal committee of the BMA, MJA, vol 2, 1919, p.209, vol 2, 1921, p.91, vol 2, 1922, p.448. 72 MJA, vol 2, 1952, op. cit. p.490. 73 For example, the report of the medical superintendent at St Vincent’s Hospital in Melbourne, for the years 1941-42 notes that ‘patients appear to be more elderly than before’, B. Egan, Ways of a Hospital, St Vincent’s Melbourne, 1890s-1990s, Allen & Unwin, St Leonards, NSW, 1993, p.178. 74 The development of neonatology in the 1930s meant that chronological age was also disappearing as a factor to be taken account of in the medical care of premature and sickly babies, McCalman, 1998, op. cit. p.244-5.
51 cases. In doing so they expanded their understanding of working within the conventional model of disease, as older patients provided more instances of the pathological conditions in bodily systems or organs around which specialists were building their expertise. 75
The effectiveness of medical interventions in ageing adults in the 1950s may be open to debate. In 1954 H. O. Lancaster, from the School of Public Health and Tropical Medicine in Sydney, noted that ‘it is well known that modern therapy has had little effect, with the notable exceptions of diabetes and pernicious anaemia’.76 Where other commentators associated the increasing numbers of infirm old people in the 1940s with advances in medical capacity,77 Lancaster looked to changes in mortality and morbidity amongst younger age groups leading to the situation where more people lived into old age. On the other hand, in 1953, Eric Saint, a physician researcher in the Clinical Research Unit at the Royal Melbourne Hospital and Walter and Eliza Hall Institute, published a study of the health of 70 patients over the age of 65, attending the outpatient department of the Royal Melbourne.78 He concluded, in contrast to Lancaster, that the specialist medical care this group received in the hospital had enabled those concerned to lead happier and more satisfying lives. Saint’s study also showed that relatively mundane medical interventions brought significant changes in the quality of life of elderly people as the pain and discomfort of ‘peptic ulceration, gall bladder disease and prostatomegaly’, were relieved, and the ameliorative treatment of degenerative conditions in otherwise capable men and women, eased their frustration and made life more tolerable. In the case of one 70-year-old a complex operation enabled him to return to his work as a crane driver. Most of the men however, lived in retirement, growing vegetables and keeping fowls to supplement their pension. The women, in most cases, continued in their lifelong occupation of housekeeping.79
75Rosen, op. cit. p.16. 76 H. O. Lancaster, ‘Aging in the Australian Population’, MJA, vol 2, 1954, p.550-551. 77 ‘The Problem of the Aged’, anonymous comment, MJA, vol 2, 1946, p.459, ‘Medicine cannot ignore the problem that has arisen. … the medical scientist has incurred grave responsibility in creating vast numbers of old people …’. 78 E. G. Saint, H.F. Albrecht, C.N. Turner, ‘Old Age: A Clinical, Social and Nutritional Study of Seventy Patients Over Sixty-Five Years of Age Seen in a Hospital OutPatient Department in Melbourne’, MJA, vol 1, 1953, pp.757-764. 79 Ibid. p.762.
52 Not all old people did well within the new medical regime. Failure to respond favourably in the ‘hygienic machine’ of the hospital where diseased bodies could be ‘restored, recalibrated and repaired’, may have arisen from the limitations of these activities. At the same time recovery may also have been impeded by lack of attention to needs old people had that were not met through recalibration and repair.80 David Browne’s success in treating the 84 year-old was not only a matter of technical skill. It was due also to the nursing care she received, that she was able to occupy a hospital bed for as long as she needed it, and that her family were attentive to her needs. Elderly patients were often at a disadvantage as the focus of medical treatment shifted towards the active manipulation of the constituent structures of the body through routine and standardised technical measures, and away from assisting the body to marshall its own resources against trauma and disease, in its own time, aided by exemplary nursing care.81
Old people were at a disadvantage because often the identification of their disease was a less straightforward process than in a younger adult. Clinical signs might not have the same significance as in youth and maturity, and pathological processes were often superimposed upon those associated with ‘involution and atrophy’.82 Second, in a publicly funded hospital system, the pressure of putting expensive resources to the best use meant that the turnover of patients was essential. As the tempo of hospital work became faster, elderly people who were slower to respond suffered, unless they had the resources to pay for their care. An uneasy acknowledgment of how badly they were served may underlie what appears to have been a callous response in medical staff to the appearance of a very old patient in the ward. Vernon Davies, a physician who took up
80 R. Stevens, In Sickness and In Wealth, American Hospitals in the Twentieth Century, Basic Books, Inc. Publishers, New York, 1989, p.19. Rosenberg presents this process as one in which patients are seen in terms that transcend their individuality, C. E. Rosenberg, The Care of Strangers, The Rise of America’s Hospital System, Basic Books, Inc., New York, 1987, p.152. From a Foucauldian perspective, the advent of scientific medicine was a social process that produced the patient as an individual, in this case an ‘ageless’ individual, the characteristic ‘free individual’ of Western Liberalism, D. Armstrong, ‘Foucault and the Sociology of Health’, in Foucault, Health and Medicine, eds A. Petersen & R. Bunton, Routledge, London and New York, 1997, p.22. 81 McCalman, 1998, op. cit. p.77; G. Canguilhem, ‘Bacteriology and the End of Nineteenth-Century “Medical Theory”’, in Ideology and Rationality in the History of the Life Sciences, trans. A. Goldhammer, The MIT Press, Cambridge, Massachusetts, 1988. 82 A. N. Exton-Smith, Medical Problems of Old Age, John Wright & Sons Ltd, Bristol, 1955,p.20.
53 psychiatry late in his career and worked with old people, tells of a favourite pastime amongst his group of doctors training at the Alfred Hospital in the 1920s. While one of them was enjoying an evening off duty, the others amused themselves by filling in a blank admission card with a fictitious name and provisional diagnosis for a new patient supposedly admitted to absentee’s ward. The point of the joke was to observe his or her reaction on realising that ‘the only vacant bed in his ward had been occupied by a man, aged 80 years, suffering from osteoarthritis and probable arteriosclerosis of the brain.’83
Throughout the early decades of the twentieth century old age became increasingly medicalised in that the ailments of ageing adults were more usually described in terms of disease conditions. The term ‘senility’, as Haber points out, originally designated ‘that which is suited to age’, a value-neutral term that in course of the nineteenth century came to refer to disorders in the very old with a connotation of hopelessness.84 In Australia the term gradually began to disappear from the medical lexicon in the first half of the twentieth century. In Cumpston’s history of disease in Australia, written in the late 1920s, he listed heart disease, cerebral haemorrhage and cancer as the active causes of death in old age, but then also used the term ‘senility’ to refer to other degenerative conditions.85 If the Victorian Year Books are any guide, during the 1930s and 1940s, ‘old age’ disappeared as a cause of death and was replaced with diagnostic terms relating to specific disease conditions. The term ‘senility’ was used in some instances, but with the accompanying phrase in brackets, ‘unknown or ill-defined’, which suggests it had become some kind of residual category. While the expression may, in some cases, have referred to the incomplete knowledge of the medical practitioner who signed the certificate, it also suggests that doctors were increasingly explaining the cause of death in terms of disease conditions. ‘Old age’ became a residual category, awaiting further developments in medical knowledge.
Stephen Katz situates the beginning of the process in which the aged body became medicalised, - that is ‘invested’ with ‘the meanings of old age
83 MJA, vol 2, 1959, p.43. 84 Haber, 1983, op. cit. p.72-73. 85 J. H. L. Cumpston, Health and Disease in Australia, A History, ed. M. Lewis, Australian Government Publishing Service, Canberra, 1989, p.133.
54 through a set of perceptual techniques that equated pathological disease, decline, and incapacity with the normality of the aged body’ - in the Paris hospitals in the nineteenth century. 86 Certainly theories relating to a medically reductionist view of the aged body emerged from the work of Charcot and his colleagues during this period, but in practice this theory was sidelined by medical practitioners who were more interested in enlarging their understanding of disease processes rather than aged bodies. To the extent that old age was medicalised throughout the first half of the twentieth century, it was on this basis and age was excluded from the picture. Those old people whose conditions were not amenable to single disease oriented interventions were, from the conventional perspective, out of place in the acute hospital. When they could not be discharged because they lacked social support, they were handed over to the almoner, later given the title of social worker.87 The introduction of this role into hospitals under medical patronage was, as Charles Rosenberg points out, an acknowledgment of the role of social factors in illness, a residue of the medical understanding of disease that preceded the medical reductionism. It was the social worker’s role to attend to needs that could not be met by medical services as they were provided in the hospital, and in this respect, the aged were one segment of that group of patients who could not be cured.88
Old Age in the Organisation of Medical Work The argument to this point has been that advances in therapeutic capacity in the first half of the twentieth century brought more patients suffering from conditions common with increasing age within the everyday work of medical practitioners in the hospitals. The introduction of a daily benefit for each occupied bed in the public hospitals by the Chifley government in 1945, to replace means-tested hospital fees, made these therapeutic advances available to a broader section of the population.89 Advanced
86 S. Katz, Disciplining Old Age, The Formation of Gerontological Knowledge, University Press of Virginia, Charlottesville, 1996, ‘The Aged Body’, p.47. 87 R. J. Laurence, Professional Social Work in Australia, Australian National University, Canberra, 1965, p.71ff. 88 Rosenberg, 1987, op. cit. p.312-313. 89 Kewley, op. cit. p.354, the Commonwealth contribution to the cost of acute care for certain groups in public hospitals continued after the Menzies’ Liberal-Country Party coalition came to power in 1949. The ideology shifted however from Labor’s recognition of the right of citizens to free hospital care, to the Liberal’s provision for the ‘deserving poor’, p.355.
55 medical skills in treating degenerative conditions were gained at the cost of relegating age-related factors into a residual category for which the social worker took responsibility. In practice, in Victoria, and indeed throughout Australia, the incorporation of older adults within the reductionist model of disease was not quite as cut and dried as has been suggested. The model was adapted to local medical practice by entrepreneurial, self-educated practitioners; confident in their abilities and unconstrained by the longstanding traditional division of labour between consultants and general practitioners that characterised English medical practice.90 Most doctors who cultivated specialist skills did so as general practitioners: not all sought membership of one of the two Royal Colleges, and many who did so continued in general practice.91
Under these conditions the conventional model of disease processes was incorporated into an individual practitioner’s repertoire of skills and tacit knowledge, an empirical approach built upon the combination of treating a wide range of patients and a self-motivated drive to absorb and develop innovations. David Browne’s treatment of the old lady’s fractured leg exemplified this approach, as he applied what he had learnt in the management of fractures at the Alfred Hospital under the direction of Ian Hamilton Russell.92 It was the broad interest and wide-ranging skills of
90 R. Stevens, Medical Practice in Modern England, The Impact of Specialization and State Medicine, Yale University Press, New Haven, 1986, p.4-5. Notwithstanding the traditional division between consultants and general practitioners, specialisation was slow to be accepted by the English medical profession. The original Royal Colleges of Surgeons and of Physicians were defined by a culture of generalism and the growth of new professional groups around special interests in the interwar period, each with its own status and control over standards, was a threat, not only to general practitioners but also to the standing of these Colleges, p.106. 91 Australian doctors were interested in acquiring specialist knowledge but as independent and entrepreneurial practitioners, a situation that arose out of local circumstances. Postgraduate training facilities were limited and the Victorian branch of the British Medical Association established a permanent Post-Graduate Training Committee after 1920, to co- ordinate postgraduate training in the state, and to assist doctors who could afford to do so, to organise training posts overseas. Also, particularly in locations away from the larger metropolitan populations of Sydney and Melbourne, there was not the population to support specialisation although after 1900 the level of patient demand rose as the cost of private consultations fell relative to wage levels. Specialists grew steadily in numbers during the period between 1947 and the late 1960s and the introduction of differential medical benefits in the late 1960s made specialisation more attractive financially, Pensabene, op. cit. pp998, pp162-165; for an account of post-graduate training up to the early 1950s from a medical practitioner’s perspective, see, A.M. McIntosh, ‘The Development of Post-graduate Training in Medicine in Australia’, MJA, vol 1, 1951, pp.28-32. 92 Browne was interested in gaining the higher qualifications that would enable him to qualify for membership of the Royal Australasian College of Physicians but was deterred by the need to earn a living immediately. He studied for the examinations in his isolated country practice but, to his great disappointment, did not pass them, Browne, op. cit. p.67.
56 Australian medical practitioners that made them disinclined to find anything of interest in Nascher’s advocacy of the specialty of geriatrics. The doctor providing personal medical services in Australian conditions would consider that he or she already took note of the social factors that might contribute to a patient’s illness, and look for a response to therapeutic measures consistent with that patient’s individual condition and this would include age. The medical care of old people was but one element in the work of medical practitioners who prided themselves on being able to attend to the every need of every one of their patients.93
As the medical profession sought to come to terms with the effects of increasing specialisation however, the medical care of the ‘elderly patient’ as opposed to the ‘case’ of circulatory failure or endocrine deficiency, began to emerge as a special area of work characteristic of general practice. Throughout the 1930s and 1940s general practitioners without specialist skills began to express their unease at the changes they saw arising out of specialisation in medical work. One of them enumerated the various aspects of this situation in 1937. Dr Winter-Ashton’s list included diminished access to hospital beds and operating facilities; the loss of patients as they went directly to specialists or when, having been referred to a specialist, they were retained in the care of that practitioner instead of being sent back to the referring GP; and the growing tendency for patients to use the Outpatient Departments of the public hospitals for the type of service that a general practitioner would otherwise provide.94 The trend towards specialisation, Winter-Ashton wrote, was leading to the situation where the general practitioner would be left with a practice that consisted entirely of rheumaticky old ladies and children afflicted with the common cold.95
93 C.B. Blackburn, ‘The Growth of Specialism in Australia During Fifty Years and its Significance for the Future’, MJA, vol 1, 1951, p.21. 94 Around 1930 the working-class began to use hospital outpatient departments in preference to the services provided through Friendly Society or Lodge doctors, Pensabene, op. cit. p.98. 95 G. Winter-Ashton, ‘Common Problems in General Practice’, MJA, vol 2, 1937, p.256; for a summary of the discontents of general practitioners see B. Gandevia, ‘A History of General Practice in Australia’, MJA, vol 2, 1972, p.382-383. These included access to hospital beds for their patients, and operating facilities and, not least, the desire to maintain their level of income which they believed was being eroded by the emergence of specialist practitioners.
57 Not all general practitioners viewed the care of old people as the least interesting aspect of medical practice. The anonymous author of a leading article in the Medical Journal of Australia in 1943 commended Malford Thewlis, I. L. Nascher’s disciple, for drawing attention to the medical care of the elderly in the pages of an American medical journal, although he was scornful of the term ‘geriatrics’ to describe this aspect of medical work, and ridiculed the notion of the specialist ‘geriatrician’.96 The family doctor, the article continued, ‘is quite equal to the task of shepherding the old people of his practice through their illnesses’, because he had a thorough understanding of each patient’s individual general make-up and family history, both of which were essential components of successful treatment.
The special role of the general practitioner in relation to elderly patients was also taken up by reviewers of the texts produced in the United States in the course of the 1930s and 1940s in which a scientific interpretation of ageing was combined with a clinical view of health and illness in old age.97 E. V. Cowdry’s collection, The Problems of Ageing, Biological and Medical Aspects, was commended for the quality of the research it exhibited as well as the insights it provided into clinical practice.98 Similar praise was evoked by E. P. Boas’ text, Treatment of the Patient Past Fifty,
96 ‘Leading Article’, MJA, vol 1, 1943, p.349. These comments may have reflected distaste, not only for specialisation, but also for Americanisms. When a small group of English doctors formed a special interest group on the medical care of the elderly in the late 1940s, they initially chose the title, The Medical Society for the Care of the Elderly, to avoid the term geriatrics which they regarded with suspicion because of its American origins. This reluctance was overcome later and the group was renamed the British Geriatrics Society in 1960, T. H. Howell, ‘Comment, Origins of the British Geriatrics Society’, and F. Adams, ‘Comment, Origins and Destiny of British Geriatrics’, Age and Ageing, vol 3, no 2, 1974, pp.62-72, and vol 4, no 2, 1975, pp.65-68. 97 See N.W Shock, A Classified Bibliography of Gerontology and Geriatrics, Supplement One 1949-1955, Stanford University Press, Stanford California, a second volume, Supplement Two 1956-1961, followed. Nathan Shock was Chief of the Gerontology Branch, National heart Institute, National Institute of Health and the Baltimore City Hospitals. He listed material from the United States, Britain and Europe, in categories such as biology, law, physiology, psychology, social welfare, longevity, and historical works. Shock visited Melbourne in 1970 to address the 19th Annual Meeting of the Victorian Council on the Ageing, ‘A Time of Change’, Victorian Council on the Ageing. 98Achenbaum, op. cit, describes this text as marking the point at which, in the United States, knowledge about the ageing process in later life, gerontology, shifted from the dubious status of the ‘Fountain of Life’ literature to a respectable field of scientific enquiry. It occurred as respected investigators in a variety of fields, and associated with respected institutions, directed their attention to the ageing process within their own disciplinary fields. Cowdry was exemplary in this respect being a scientist experienced in the fields of anatomy, zoology, and cytology, working in prestigious institutions such as Johns Hopkins and the Rockefeller Institute and Washington University, pp. 62-76. The presentation of this knowledge in the form of a handbook in which ageing was interpreted from the
58 the first in a series of American General Practice manuals, which was to run to several editions.99 Boas was commended for providing information to enable the practitioner to distinguish between ‘pure senescence and disease’ as well as for his descriptions of common diseases.100
On the basis of texts such as these, general practitioners - so reviewers claimed - would be able to extend their range of competence to become ‘the chief agent of preventive medicine in the field of chronic diseases’.101 Implicit in this conception of the role of the general practitioner is the understanding that it will be undertaken by the personal doctor working in solo practice, combining the most up-to-date biological and biochemical knowledge with a personal knowledge of the constitutional and social particulars of individual fee-paying patients.
By the late 1940s, the problems general practitioners had first described in the 1930s, were compounded by a greater workload arising from the post- war expansion in population and a level of remuneration that, one commentator notes, had been unchanged over the previous fifty years.102 The association between general practice and the medical care of the elderly was reinforced at this time. This occurred not through the promotion of an organised body of knowledge in relation to old age, nor the provision of age related medical services, but as a consequence of the introduction of a national system of hospital and medical insurance. One component in this scheme, the Pensioner Medical Service (PMS), ensured that medical services for the poor elderly and the chronically ill, were allocated to general practice. Even then, because doctors could choose
standpoint of a number of disciplines proved to be the model for later volumes of gerontological knowledge. 99 E. V. Cowdry reviewed, MJA, vol 2, 1939, p.836, E. P. Boas reviewed vol 1, 1942, p.318. 100 L. Davidow Hirshbein, ‘ “Normal” Old Age, Senility, and the American Geriatrics Society in the 1940s’, Journal of the History of Medicine and Allied Sciences, vol 55, no 4, 2000, pp.337-362. The American Geriatrics Society was formed in 1942 with the objective of promoting the medical knowledge to enable doctors to make the distinction between normal old age, which did not interfere with function, and senile deterioration – the evolution of serious deficiency and disease. The Society’s approach was based on arguments for the need for intensive medical supervision in later life. As Hirshbein points out, this is indeed what occurred in the 1950s and 1960s, but not under the control of self- appointed geriatricians but general physicians. Texts such as Boas’ illustrate this development. 101 MJA, vol 1, 1943, op. cit.p.350. 102 R. Winton, A’Body’s Body, The First Twenty-One Years of the Royal Australian College of General Practitioners, The Royal Australian College of General Practitioners, 1983, p.13.
59 whether or not they would participate in the Service, the association was up to the individual practitioner. The PMS, introduced in 1951, and the Pharmaceutical Benefits Scheme which accompanied it, were two elements in the system of hospital and medical insurance introduced by the Liberal–Country Party Coalition Government which came to power in 1949. The focus on the elderly in this scheme did not represent any attention to their particular needs, except in relation to the capacity to pay for personal medical services. It was a side-effect of an overall process orchestrated by the Australian branches of the British Medical Association (BMA), directed towards protecting the economic position of the general practitioner in which the Commonwealth assumed the responsibility for paying for the highest risk patients – the poor aged and the chronically ill.103
In taking this step, the federal government, led by Robert Menzies, was responding to an agenda set by the previous Labor administration when it attempted to install a national, publicly-funded system of hospital and medical insurance similar to that introduced in Britain in 1948.104 Labor’s venture was frustrated at an early stage when the state branches of the BMA combined to secure a ruling by the High Court that the Pharmaceutical Benefits Scheme, the first element of Labor’s scheme, was unconstitutional.105 The succeeding administration, in which the Minister for Health, Dr Earle Page - himself a surgeon and member of the BMA - converted the idea of a universal, publicly-funded, health service into a form more acceptable to the conservative elements of Australian society. That is, his proposals included the provision of assistance to the ‘deserving
103 Kewley, op. cit. p.367; Gillespie, op. cit. Ch 11. 104 This agenda had been first introduced in the 1920s following the Royal Commission on National Insurance, 1924-1927, and the Royal Commission on Health, 1925, when JHL Cumpston, Director of the newly established Commonwealth Department of Health, urged a national approach to the provision of medical services, J. H. L. Cumpston, The Health of the People, A Study in Federalism, A Roebuck Book, Canberra, 1978, p.15-16, p.46-47. Interest in a national insurance scheme (contributory this time) reappeared in the late 1930s, although without the comprehensive view of health services espoused by Cumpston who gave equal prominence to preventive and curative measures. Nor did the non- contributory, national scheme for the provision of hospital and medical services, proposed by Labor in the 1940s, extend any further than the provision of personal, curative medical services, Kewley, op. cit. p.342ff. 105 Gillespie, op. cit. p.253ff, Gillespie makes the point that the situation was somewhat more complex. Opinion regarding a fee-for-service within the BMA was divided and in the course of the 1940s when the matter of postwar health services was under discussion, there was support for a national salaried medical service which the Labor government failed to take advantage of, concentrating more on access to services rather than provision. p.130ff.
60 poor’, who by this time were classified as eligible aged or invalid pensioners, at the same time as it encouraged the virtue of self sufficiency in the rest of the population through the moral and financial support of private hospital and medical insurance.
This solution was acceptable to the BMA because, among other things, it preserved the fee-for-service basis regarded by the Association as vital to the integrity of the doctor-patient relationship.106 The PMS provided general practitioner services and free medicine to eligible aged and invalid pensioners through the direct reimbursement of doctors, according to tables of fees agreed to by the BMA, for the cost of consultations. It did not include the cost of specialist consultant services. For those, pensioners had to attend the outpatient departments of the public hospitals where consultants provided their services on an honorary basis. When pensioners required inpatient care, hospitals were directly reimbursed by the Commonwealth for the costs incurred.107
The Pensioner Medical Service, in addition to the services provided by general practitioners for the Repatriation Department for returned service personnel, provided an organisational basis for the role of the general practitioner as the ‘chief agent of preventive medicine in the elderly and the chronically ill’.108 In 1958, the establishment of the Australian College of General Practitioners, with Faculties in the States, opened the way to supplementing this organisational base with a knowledge base relevant to general practice, to be included as an element of undergraduate training and forming the basis of a postgraduate qualification.109 The College’s objectives included the promotion of a ‘scientific approach to problems of disease at the level of the individual and the family’; the prevention of disease and the welfare of the community; the promotion of postgraduate
106 Gillespie, op. cit. pp.273-276. 107 Kewley, op. cit. pp.367-370. 108 MJA, vol 1, 1943, op. cit. The services available under both schemes differed in comprehensiveness so that wherever possible, elderly persons who qualified for a Repatriation Department pension would chose that benefit, Kewley, op. cit. p.425. 109 The primary aim of the College was to develop and maintain ‘the highest standards in general practice’, an aim that took some time to realise because of differences within the College as to how it could be achieved. Winton, op. cit. pp.18-25.
61 education for GPs; and research into ‘conditions most frequently seen and appropriately studied in general practice’. These objectives were underpinned by the perception that the concept of clinical research could be applied to patients in their homes and GPs’ consulting rooms in order to clarify aspects of disease that were not apparent in hospitals.110 There was, however, no indication of what form the knowledge that defined the GP’s role would take, and from the beginning the possibilities of this educative and training enterprise succeeding were limited. Founding members were divided amongst themselves as to how to go about developing the educative role of the College, and its potential strength was undermined because, unlike the other medical Colleges, fellowship of the Australian College of General Practitioners was not a prerequisite to entering general practice.111
Eric Saint’s study of a small group of elderly patients at the Royal Melbourne Hospital suggests that by the 1950s the experience of ageing had begun to change for many Victorians. Paradoxically, as chronological age appeared to become less of a factor to be taken into account in therapeutic decisions, it became more relevant socially as age-related welfare measures opened up the possibility of more ageing Australians benefiting from these advances. In this postwar period, the growing tendency to categorise the elderly as a social group, and old age as a ‘stage’ of life, was still closely related to the relief of poverty. Changing social and economic conditions only made the classification process more widespread. As ‘retirement’ became a more common experience for both working and middle classes because of the Age Pension, old age began to emerge as a discrete ‘stage’ of life in a fashion similar to the identification of childhood and adolescence as ‘stages’ of life, earlier in the twentieth century.112
110 Ibid. p.22-23. 111 Sally Wilde notes the founders of the College were more preoccupied with the trappings of collegiality rather than the substance. The prefix ‘Royal’ was sought, and granted in 1969, well before the College had sorted out its role in establishing the specialist field of general practice, S. Wilde, 25 Years Under the Microscope, A History of the RACGP Training Program, 1973-1998, Royal Australian College of General Practice, South Melbourne, Victoria, 1998, p.2-3. 112 S.Harper & P. Thane, op. cit.
62 From the technical, laboratory-based perspective of the specialist practitioner in the general hospital, old age was a residual category, applicable to those for whom medical science could provide no relief in their afflictions. The situation was quite clear-cut. The social worker assumed responsibility for elderly patients who were not improved by medical treatment, but who could not be discharged because they had nowhere to go. In the community the position of elderly patients in general practice was less clear. On one hand the work of general practitioners was informed by the same cognitive orientation found in the hospital, an orientation in which there was no place for explaining any patient’s condition simply in terms of advanced age. Yet on the other hand, the medical care of the elderly, along with the chronically ill, had emerged as the special preserve of the GP based on his or her personal understanding of each individual patient’s condition. Within this context there was scope for taking account of a patient’s age, and interested medical practitioners could now extend their personal understanding of the ageing process through the texts that became available in the postwar period. However, any development of the GP’s knowledge base was confined to the efforts made by the individual practitioner and there was no institutional back-up for treating old people for whom individualised, curative medical services were ineffective. In comparison with the GP’s role in relation to younger patients, the care of infirm old people was unchanged in its fundamental approach from that provided by that practitioner’s nineteenth century predecessors. In both hospital and community, when the condition of an old person was not amenable to cure or management through the standardised ‘recalibration’ of bodily organs and systems, they were, to all intents and purposes, outside the realm of active medical work.
At the session on the medical care of the aged during the Australasian Medical Congress in Melbourne in 1952, Dr Alan McCutcheon, medical officer at Mount Royal Home and Hospital for the Aged, expressed a view of this group of patients that would have been representative of many other doctors.113 He categorised old people into three groups. The first were able to live a ‘fairly normal life’, keeping active almost ‘to the end’. The
113 MJA, vol 2, 1952, op. cit. p.489.
63 second included those who were unable to look after themselves because of frailty or lack of resources. Both these groups were well provided for through existing medical and welfare services. The third group, he said, posed the most serious problem and they were those old people whose condition was irremediable and who needed long-term care. They were out of place in the general hospital because it was inefficient to use such costly resources to provide the care they needed, and in any case these resources could not provide any solution to their condition.114 He concluded that what was needed in these circumstances was greater provision of accommodation for this group, and that in this respect the needs of the infirm aged constituted a social problem, not a medical one.115 In Victoria there was little change in the response of doctors to old age infirmity in the period from the late nineteenth century to mid-twentieth century. In contrast to the gradual divergence during this period between popular and medical views of sickness, as far as old age infirmity was concerned community and medical views coincided in calling for the provision of custodial care through the activities of charitable citizens.116
Conclusion: Old Age Infirmity – A Medical or a Social Problem? The argument in this chapter has been that as old people became more prominent in the Victorian population in the first half of the twentieth century, and more of the afflictions they experienced became amenable to medical intervention, the category of ‘old age’ disappeared from legitimate medical explanations. It was reserved for those old people who could no longer be maintained in good health by the personal curative services provided in hospitals and general practice. Their condition, especially when they lacked the resources to provide for their own needs, was recognised by both medical profession and the public at large, as a generic problem of old age. It was merely a problem that required a community response along long-established lines in Victoria – the marshalling of charitable forces to made adequate provision for custodial care.
114 Ibid. 115 Ibid. p.490. 116 Alan McCutcheon exemplified this approach when, speaking at one of the regular Pleasant Sunday Afternoons conducted at Wesley Church in Melbourne, he deplored the possibility of a nationalised health service as it was proposed by the Chifley Labor government, because it would diminish the charitable impulse in the community, The Age, 27/10/47.
64 It was not inevitable that generically infirm old people should be excluded from active medical work. For example, had J.H.L. Cumpston been successful, in the early 1920s, in establishing the Commonwealth Department of Health as a provider of personal, preventive medical services, so that ‘every individual human unit’ experienced ‘positive health, being free of disease and disability’, the position of infirm old people in relation to medical work may have been very different.117 One aspect of the role Cumpston envisaged for the general practitioner as public health officer was the supervision of a system of publicly funded preventive and rehabilitative services, instead of the existing practice of providing cash benefits in the form of the Invalid Pension, and charitable care in institutions such as the benevolent asylums in Victoria.118 There is no reason to believe that the infirm aged would have been excluded from such services.
In fact from early in the twentieth century Australian doctors had shown that they understood the multi-dimensional nature of illness and the possibility that the medical role encompassed more than curative services. In forms that varied according to conditions in individual states, the role of public health officer whose concerns were principally with sanitary conditions, was complemented early in the century by the role of school medical officer and by the introduction of services directed towards the health of mothers and babies.119 The services provided by the Repatriation Department, to assist the return of permanently injured service personnel to civilian life, following service in the 1914-1918 conflict, established a model for a medical response to conditions that were not amenable to curative medical services.120 It was the experience of doctors in controlling and preventing disease amongst the troops that stimulated the founders of the Commonwealth Department of Health to attempt to establish a similar medical role in relation to everyday civilian life.121
117 Cumpston, 1978, op. cit, p.16, pp.46-47; Roe, 1976, op. cit. 118 Gillespie, op. cit. p.43-44; Cumpston, 1978, op. cit. p.8. 119 Cumpston, 1978, op. cit. lists these measures which, he hoped, could be extended in some form to the whole population. p.46-47. 120 C. Lloyd & J. Rees, The Last Shilling, A History of Repatriation in Australian, Melbourne University Press, Carlton, 1994, p.114. 121 Gillespie quotes Cumpston describing the enthusiasm of his medical colleagues on their return to Australia ‘filled with a desire to apply to the civil community the great lesson of
65 The organisation of medical work that emerged in the early 1950s, one that was to remain unchanged for the following twenty years, represented the outcome of a number of intra-professional debates over the preceding thirty years. These debates addressed the question of how medical services ought to be paid for, the place of the general practitioner in an increasingly specialised profession, and the relationship between the medical profession and government. Differences of opinion on these topics within the profession, were exacerbated by the varied approaches to providing health services in the states and by conflicts between the states and the Commonwealth. Nonetheless, the organisation of medical work that emerged with the introduction of the Page scheme in the early 1950s, reflected a degree of unity within the profession that in having settled on a formula for government subsidy of medical services without compromising medical autonomy, the way was open for the advance of medical expertise. It was the general acceptability of the view amongst doctors that individual medical services based on a developing technical expertise was the best approach to problems of disease that underpinned the emphasis on systems of payment. In these circumstances the voices of a minority of doctors who, like Chris McCaffrey, medical superintendent of the Royal Newcastle Hospital in New South Wales, believed that health policy should be concerned with broader matters than how doctors and hospitals were to be paid for treating patients, were lost.122
The emphasis in Victoria in the early 1950s, on the provision of curative medical services – in terms of both the organisation of medical services and the reductionist research that underpinned them – is understandable to some extent. Neglect of the State’s hospital services during the Second World War, and the Depression that preceded it, and then the demands placed on inadequate services by an expanding population, had led to the situation where investigative, research and treatment facilities in all Australian hospitals lagged well behind the models Australian doctors
successful medical control and prevention of disease which had been applied in the army’, Gillespie, op. cit. p.31. 122 Gillespie, op. cit. pp.280-282.
66 found in Britain and the United States.123 The perceived deficiency of these resources, and the desire on the part of Australian doctors to participate in a worldwide medical fraternity based upon them, led to the position where the whole emphasis in the development of postwar health services was on the establishment of hospitals and laboratory research. It was an emphasis that received community support also, the provision of hospitals being generally regarded as the best means of dealing with problems of illness.
Nevertheless, despite the overall emphasis on providing curative medical services and establishing laboratory and clinical research programs, an undercurrent of interest persisted amongst a small segment of the medical profession which was interested in addressing the needs of individuals whose conditions were not immediately amenable to these approaches. It was the slow and uncertain melding of their concerns into a coherent model of medical services that opened up the possibility for an active medical role in relation to generalised old age infirmity to be established. The remainder of this thesis examines, how, between the early 1950s and the late 1970s, in Victoria, this emerging model was integrated into the overall pattern of medical work, thus opening up the possibility of establishing old age in general as a medical specialisation.
123 K. F. Russell, The Melbourne Medical School, 1962-1962, Melbourne University Press, Carlton, Victoria, 1977, p.184ff; R. D. Wright, ‘Before and After’, The Halford Oration, MJA, vol 2, 1950, pp.637-640.
67 CHAPTER 2 THE UNKEMPT GARDEN OF CHRONIC SICKNESS AND INFIRMITY1
Introduction The previous chapter concluded that, within the pattern of medical practice that took shape in Victoria in the early 1950s, medical and community opinion coincided in regarding the care of the infirm aged as a social, not a medical problem. This chapter examines the ideas, community activities, institutions, government activity and organisation of the medical profession that underpinned this point of view. Themes that emerged in the first chapter – community responses to old age, state/federal relations, the public funding of hospital and health services, the relationship between medical ideas about sickness and the organisation of medical services and the interaction between the community and the profession in providing services – are presented in greater detail.
In the mid-1950s, Dr John Lindell, first medical Chairman of the Hospitals and Charities Commission in Victoria, proposed to introduce a medical role in providing hospital-based services for candidates for custodial care. The purpose of this chapter is to examine the professional and social context in which this decision was situated, a process that leads to a juxtaposition of ideas and institutions which, although focused on Victoria, does extend into other states and the Commonwealth. The reason for doing this is to situate the role of ‘geriatrician’, a specifically local response to local needs, within a broader, but fragmented, professional context in which a segment of the Australian medical profession sought to establish socio-medical services. This digression into activities outside Victoria is intended to highlight the general lack of interest in such services amongst Victorian doctors and to provide a background for Chapter Five where I argue that ‘geriatricians’ in Victoria
1 Michel Foucault uses the term ‘unkempt garden’ to describe the wards of the Paris hospitals prior to their reorganisation in the service of pathological medicine. In this process sick bodies were ordered so that disease was displayed to the medical ‘gaze’ and the hospital ward became a research and pedagogical tool. M. Foucault, The Birth of the Clinic, trans. A.M. Sheridan, Routledge, London, 1991, p.17. When the medical ‘gaze’ shifted towards the infirmary wards of the benevolent homes in Victoria it met a similarly undifferentiated mass of infirmity in which common characteristics were rejection by the field of acute medical care and an increasing expense to the public purse.
68 were able to develop their role beyond its institutional confines because of the activities of doctors in other states, particularly in New South Wales, in establishing a nation-wide socio-medical model of practice in the 1970s.
When J.H.L. Cumpston, the first Director-General of the Commonwealth Department of Health, turned to the social medicine perspective for inspiration in developing services that addressed the complexity of disease causation, he established something of a tradition within the Australian medical profession for succeeding generations of doctors. From the 1920s on, social medicine, particularly as it was developed in Britain, provided a model for doctors who, recognising the multicausal nature of disease, wanted to establish health services that extended further than individualised, curative medical care. The terms ‘social medicine’, ‘social hygiene’ and the social science of medicine are associated with a complex of ideas about illness and the organisation of medicine, that emerged first in mid-nineteenth-century Europe and somewhat later in England. Developments in England reached a high point in the early 1940s when J.A. Ryle, a prominent physician in England, was appointed Professor of Social Medicine at Oxford. Around the same time, at three other universities in England and Scotland Chairs of Social Medicine were also established. Only a small segment of the Australian medical profession evinced any interest in social medicine and they gave it a particularly local interpretation which resulted in a form of ‘social hygiene’ designed to complement what J.A. Gillespie has described as a fundamentally materialist orientation to understanding disease.2 The health services established in Queensland in the 1930s, under the direction of Sir Raphael Cilento, including a Chair of Social Medicine in the Queensland medical school, were until the 1970s, the most developed form of ‘social medicine’ in Australian health services. Nevertheless, during the 1930s and 1940s, this small segment of the Australian medical profession did establish a rudimentary local ‘social medicine’ even if it was mostly only at the level of ideas and where it was put into practice, only on the margins of medical
2 Gillespie, op. cit. p.34,
69 work. It was within this professional context that John Lindell, developed his plans to introduce a socio-medical model of service to address the needs of the infirm aged in 1950s Victoria.
On the whole, the medical profession in Victoria showed little interest in problems of illness that were not amenable to a reductionist model of disease and medical treatment directed towards cure. Their materialist orientation to disease was complemented by a social conservatism that discredited social medicine by associating it with socialism as a form of government. Doctors that did not take this view were discouraged by the inability of Federal parliamentarians to understand that the provision of hospital beds and personal curative medical services was not a fully adequate response to the health needs of the population. However, co- existing with the general trend in the 1950s in Victoria, to stress individualised, curative medical services, there was a small community of medical opinion, at the centre of the Melbourne medical world in which social medicine was taken seriously by a few clinicians, researchers and a lone general practitioner, all of who were influenced by social medicine in postwar Britain. This centre encompassed the Royal Melbourne Hospital, the Clinical Research Unit at the Melbourne and the Walter and Eliza Hall Research Institute, and the medical school at the University. Lindell, medical administrator in the state bureaucracy and former medical superintendent of the Melbourne, moved through this world as he confronted the task of developing Victoria’s neglected hospital system and the system of educating and training doctors and other health professionals.
I argue in this chapter that Lindell’s decision to introduce a socio-medical role in the provision of geriatric services to complement the acute medical services provided in the general hospitals, was framed by a local and rudimentary notion of social medicine. This modest innovation was hedged around by the overall emphasis, in the community and in the medical profession, on curative medical services and biochemical research, and by the longstanding practice of substantial community involvement in the provision of publicly funded hospital services. The development of all hospital services in Victoria grew out of the cooperative activities of local community groups and medical
70 practitioners, activities that were funded largely by the state government. From the 1950s, this relationship was subjected to a number of strains as a financially-straitened state government attempted to impose a state-wide, rationalised system of hospitals upon an uncoordinated multitude of local responses to local perceptions of need.
Social Medicine in Australia A social medicine orientation to explaining disease, as it was developed in mid-nineteenth century Europe and England, incorporated three principles.3 First, that the health of individuals is the responsibility of society as a whole; second that social and economic conditions play as important part in the development of disease conditions as physiological changes; and third, that doctors, as a consequence, need to be involved in studying, and perhaps changing, these social conditions.4 In England the linkage between disease and social and conditions led first to the emergence of the role of public health medical officer but in comparison with European physicians such as Rudolf Virchow, English doctors were slow to incorporate the mass of material on the living and working conditions of the poor that they accumulated, into formulations of ‘social goals and ideologies’.5 By 1905 when J.H.L. Cumpston went to England to study for the Diploma of Public Health, social medicine was more clearly recognised as a form of expertise in the ‘“corporate management of communal life”’ and some education in the social sciences had been introduced into the Diploma curriculum.6 If Cumpston did come into contact with this attempt to standardise the social dimensions of illness, the experience does not appear to have influenced his adaptation of social medicine in his plans for the Commonwealth Department of Health. The
3 G. Rosen, ‘What is Social Medicine’, in From Medical Police to Social Medicine, Essays on the History of Health Care, Science History Publications, New York, 1974, pp.64-68; D. Porter, Introduction in Social Medicine and Medical Sociology in the Twentieth Century, ed D. Porter, Rodopi, Amsterdam, 1997, pp.3-7. 4 Rosen, 1974, op. cit. pp.64-68. 5 Rosen, 1974, op. cit. pp.65-67. 6 Roe, op. cit. 1984, p.119. The influence of his time in England may be discerned in Cumpston’s address on the ‘Nationalization of Medicine’ at the University of Melbourne when he quoted Sidney and Beatrice Webb, ‘avid collectors’ of data to provide the basis for social policy directed towards achieving specific social goals, p.129, also, Cumpston, 1978, op. cit. p.16, Porter, 1997, op. cit. ‘Introduction, p.6.
71 Department was established in 1921 with Cumpston as the first Director General.7
Cumpston’s interest in public health was aroused by conditions that he knew to be preventable, the cases of typhoid fever and hydatid infestation that he saw in hospital wards. His response to a situation in which disease was clearly associated with social and economic conditions, was to propose an enlargement of the role of public health medical officer (a role modelled on the English example), and the provision of health services by the Commonwealth. The role of salaried, public health officer was intended to facilitate extended expert medical intervention in unhealthy social conditions through the establishment of regional health centres with the laboratory facilities not available to doctors outside the large cities. From these centres data on health and sickness in the population would be collected and the appropriate preventive measures developed and applied as public policy. Cumpston’s practical response to the social dimensions of disease is quite distinct from, for example, that of Virchow, for whom the practical content of social medicine was a medical intervention in political and social life.8 Cumpston, on the other hand, sought to develop a form of national hygiene, an extension of existing public health regulations, underpinned by a ‘medical materialism, in which political and economic phenomena appeared as the social manifestations of more fundamental medical causes’.9
Cumpston was led to a career in public health not because laboratory- based medicine provided an inadequate understanding of disease, but because medical expertise was limited in its effectiveness by social and economic conditions.10 The hygiene, or art of healthy living envisaged by Cumpston, did not arise from a perception of the limitations of ‘scientific’ medicine. It was associated with the view that in Australia, medical practice was insufficiently scientific because an entrepreneurial medical profession was blinkered in its outlook and impoverished by lack of resources. Greater state intervention was needed to develop the capacity
7Roe, 1976, op. cit. p.180. 8 Rosen, 1974, op. cit. p.65-67; Cumpston, 1978, op. cit. p.46-47. 9 Gillespie, op. cit. p.34, the phrase ‘medical materialism’ was coined by Gillespie. 10 Cumpston’s interest in public health was reinforced by the financial perils of setting up private practice at the time, Roe, 1984, op. cit.
72 of medicine to shape the everyday life experience of individuals in the name of national efficiency.11 Cumpston’s medical hygiene differed from social medicine in that it was directed to extending the model whereby disease was explained in biochemical terms. This was to be achieved by first the introduction of a range of publicly funded medical services and laboratory facilities by the Commonwealth government. Second, by an enlargement of the role of the public health medical officer from the supervision of sanitary measures to a concern with nutrition and the environments in which they lived and worked.12 These services would also include the supervision of individuals eligible for publicly funded benefits such as the Invalid Pension. The provision of welfare was to be aligned with rehabilitation and prevention.13
Overall, Cumpston’s ambitions for the Department of Health were not realised for a range of reasons. They included the difficulties surrounding any cooperative venture between the states and the federal government because of the narrow range of responsibility allocated to the latter in the Constitution, the lowly standing of the Department of Health in the Commonwealth bureaucracy, and reluctance on the part of the medical profession to align their work so closely with government policy.14 It is likely also that Cumpston’s reliance on the rationality of his proposal to justify his cause, blinded him to the necessity to appease those who
11 A similar interest in national efficiency inspired the founders of the Workers Education Association during the 1920s. The Association was part of the National Efficiency Movement in Australia, a movement that aspired to see that ‘our people shall lead healthy, happy lives; that they shall work efficiently, and have pleasure in their work; that they shall enjoy their leisure in the best and highest sense; and, above all, … be men and women of the highest rank as human beings.’ The movement was associated with a form of liberalism which looked to a ‘ “politically neutral technocratic wisdom”’ based on the disciplines of economics, sociology and psychology, Rowse, op. cit. pp.44ff. 12 Gillespie, op. cit. p.49-50. 13 Roe, 1984, op. cit. p.126. 14 Gillespie, op. cit. p.31ff. Gillespie notes that the failure of the Commonwealth Department of Health to develop along the lines Cumpston proposed, cannot be read retrospectively as opposition to a socialistic oriented system of health services. Advocates of social medicine could be found ‘across the political spectrum’, p51. Michael Roe, while noting that Cumpston was influenced by the idealism of English Liberal, T. H. Green, and the socialist Fabians, concludes that Rooseveltian progressivism was ‘the creed’ that best characterises the set of ideas that underpinned his work, although over time Cumpston tended to emphasise the English influence. Progressivism, like Green’s liberalism and Fabianism, was also a response to the failures of laissez faire capitalism, recognising a role for the state in counteracting the excesses of capitalism and the degradation of citizenship through applied science and the work of expert technicians and bureaucrats. Progressivism, Roe writes, was both radical and conservative in seeking conservative ends by radical means. Roe, 1984, op. cit. pp.7-13.
73 believed their interests were threatened.15 The failure of the Department of Health to take an active role in the provision of medical services was all the more noticeable in view of the success achieved by the Department of Repatriation in providing a range of services under medical control for returned service personnel. Repatriation, established three years before the Department of Health, provided an organisational framework for the provision of extensive medical services to returned service personnel as it supervised medical repatriation from the theatres of war, medical treatment of invalids and convalescents, compensatory pensioning of the disabled and provision of vocational training and community rehabilitation for them.16
While Cumpston’s ‘national hygiene’ was not social medicine as it was understood in Europe and England. His plans for the Department of Health implemented certain features of social medicine, in the acknowledgment that health of the population was a matter of collective responsibility, and that the medical profession had a part to play in formulating public policy on health matters.17 The tendency for Australian doctors to look to social medicine for ideas persisted throughout the 1920s and into the 1940s, as they continued to come to grips with the problem of providing an organised response to the multi-dimensional nature of disease, a response that was made more urgent in their eyes by the 1930s Depression. The clearest indication of the influence of social medicine in the pre-war period was seen in the system of health services, established in Queensland in the 1930s under R. W. Cilento (later Sir Raphael), as Director General of Health and Medical Services. Cilento, whose interpretation of social medicine, like Cumpston’s, could be described more aptly as ‘social hygiene’, established the first Professorial Chair of
15 Sir Henry Gullett, member of the House of Representatives in 1925, journalist and historian, noted there was no sign that Cumpston had any other ambition but to establish the scientific means of preventing disease and advancing the health of the people. Quoted in C. Thame, ‘The Development of Collective Responsibility for Health Care in Australia in the First Half of the Twentieth Century’, PhD Thesis, Australian National University, 1974, p.348. 16 Lloyd & Rees, op. cit. pp.79ff and p.141. 17 The establishment of several divisions in the department - marine hygiene, quarantine, and laboratories situated at strategic points throughout the country for diagnostic, research and educative work, industrial hygiene, sanitary hygiene and tropical health – indicated a commitment to the health of the nation and to contributing information for world-wide use, Roe, 1976, op. cit. p.134.
74 Social Medicine in the medical school at the University of Queensland in 1937.18
In addressing issues such as the role of the social environment in disease, the organisation and funding of medical services, and the balance in the provision of medical services, between curative and preventive services, local medical practitioners followed Cumpston in drawing upon features of social medicine from Britain. After the end of the Second World War there, social medicine gained the status of an academic discipline with the appointment of J.A. Ryle as Professor of Social Medicine at Oxford University in 1943.19 Subsequently three other chairs were established at Edinburgh, Sheffield and Birmingham.20
Ryle was one of a small group of prominent individuals in the English medical profession, including Sir William Jameson, Chief Medical Officer at the Ministry of Health, who were dissatisfied with medicine as it was then taught and practised.21 Medicine, Ryle wrote in 1943, was specialised and technical to the extent that the needs of the patient as a human being had been lost: Investigation to the limit, mainly by objective methods and often with too little said or done for the patients during or after the tedious process, … especially in the case of the more chronic or seemingly more obscure varieties of disorder and disease. … too little knowledge of morbidity and mortality figures, of the relative incidence of diseases in the community, of the vast prevalence of “illness” or “debility” without “physical signs” … too vague an appreciation of the fact that these illnesses … have discoverable
18 F. Gould Fisher, Raphael Cilento, A Biography, University of Queensland Press, St. Lucia, Qld, 1994, p.102-103. Cilento defined social medicine as ‘ “the study of the means for the constructive preservation of health”’, and tropical medicine was its practical application in Queensland, p.143. 19 Cumpston corresponded regularly with Ryle, Gillespie, op. cit. p.51. 20 Porter, 1997, op. cit. p.1-2; D. Porter, ‘Changing Disciplines: John Ryle and the Making of Social Medicine in Britain in the 1940s’, History of Science, xxx, 1992, pp.138-140. 21 D. Porter, ‘John Ryle: Doctor of Revolution?’ in Doctors, Politics and Society: Historical Essays, eds D. Porter & R. Porter, Rodopi, Amsterdam-Atlanta GA, 1993, N. T. A. Oswald, ‘A Social Health Service Without Social Doctors’, Social History of Medicine, vol 4, no 2, 1991, pp.296-305.
75 origins in social, domestic, or industrial maladjustment, in fatigue, economic insecurity, or dietary insufficiency …22
Funded by the Nuffield Foundation, the Institute of Social Medicine was to be devoted to the study of ‘social pathology’ in the form of studies of sickness in communities rather than isolated in hospitals.23 Social medicine was the discipline that would provide a social biology of human life, of the sick person in their natural environment, in order to add ‘the experience of disease from the patient’s point of view as much as that of the experimental pathologist, biochemist or physiologist.’24
The ideas disseminated from England between the 1920s and the 1940s, were used by Australian doctors in the discussions and debates that took place in a number of different arenas over this period. Out of these a local social medicine emerged which was, as James Gillespie notes, a derivative and ‘vaguely linked set of doctrines’, but nonetheless the beginnings of an organised approach to providing a social response to illness and disability.25 Medical practitioners who were interested in addressing social questions relating to medical services found a more encouraging environment when, in the 1940s, the topic of health services was included for discussion as part of the project of planning postwar national reconstruction. Under the aegis of the National Health and Medical Research Council and of the Joint Parliamentary Committee on Social Security, the question of organising health services to address the health needs of the Australian population was canvassed widely.26
However, in the national health scheme that finally emerged in the early 1950s, introduced by the Liberal-Country Party Coalition government that replaced the Chifley Labor administration in 1949, all issues had been submerged in an emphasis on the system of remuneration for medical services. It was left to the profession itself, and the State governments, to determine what health services were to be provided and how they were to
22 J. A. Ryle, ‘Social Medicine: Its Meaning and Its Scope’, British Medical Journal, vol 2, 1943, p.633. 23 Social medicine in the form established by Sir Raphael Cilento in Queensland also benefited from Lord Nuffield’s generosity, Gould Fisher, op. cit. p.143. 24 D. Porter, 1992, op. cit. p.143. 25 Gillespie, op. cit. p.51. 26 Gillespie, op. cit. pp.51-56; S. Shaver, ‘Design for a Welfare State: The Joint parliamentary Committee on Social Security’, Historical Studies, vol 22, no 88, 1987, pp.411-431.
76 be organised. The advocates of what may loosely be termed ‘social medicine’ were silenced by the earlier incapacity of the Chifley government to grasp the point that there could be more to the provision of health services than access to personal, curative services. After the war, in the political climate of the Cold War, social medicine was discredited because of the connection made, by both its defenders and detractors, between socialism and social medicine. Furthermore, the support of many practitioners for cooperation between the federal government and the medical profession in the provision of health services had been weakened in the processes of negotiation. In these circumstances, that segment of the profession prevailed which favoured personal, curative services, paid by fee-for-service, and provided according to the discretion of the individual practitioner.27
There was some recognition of collective responsibility for the provision of health services and of the part played by the social environment in illness and disability in the national health service introduced in the early 1950s.28 The Australian medical profession, represented by the British Medical Association, agreed to the inclusion of a comprehensive, publicly funded program, including curative, preventive and rehabilitative services, to tackle tuberculosis in the Australian community.29 Their agreement suggests some awareness in the profession of a collective responsibility for the provision of health services, and that to be effective these services needed to take into account social factors such as security of income and return to working life. The acceptance by the Association, of the Pensioner Medical Service and the Pharmaceutical Benefits Scheme, was also an acknowledgment that economic status could affect health status. Such expressions of collective responsibility were, however, minimal. They were cautiously confined to the eligible poor with the exception of vaccination programs and the provision of free milk to schoolchildren.
In the sense that these provisions reflected an acknowledgment of collective responsibility for the health of the nation, they may loosely be described as social medicine. It was, however, social medicine for the
27 Gillespie, op. cit. Chs. 9 and 10. 28 Kewley, op. cit. p.346ff. 29 Ibid. pp.370-373; see also Sir Earle Page, What Price Medical Care’, A Preventive Prescription for Private Medicine, J. B. Lippincott Company, Philadelphia, 1960.
77 eligible poor, provided by the general practitioner, and in the main, confined to curative services developed around the biochemical model of disease. The critique of this model that was implicit in social medicine in Britain was certainly not acknowledged in the Australian version of social medicine. Nor was there any indication that a reductionist interpretation of disease required any amplification from epidemiological studies. Once the federal government elected to confine its contribution to the nation’s health services to the provision of subsidies for the curative medical services that now constituted mainstream medical practice, the only avenue open to those medical practitioners who perceived the need for a broader approach to the prevention and treatment of illness was through the state government bureaucracies. Practices that could come under the heading of social medicine - already located at the margins of medical work because of the connection with poverty - were, in this association with government bodies, even further marginalised in a profession that regarded with odium the open involvement of medicine in the corporate activities of the state.
Care According to Cost In Victoria, in the 1920s, as the same time as Cumpston was engaged in promoting a standardised and national approach to the management of sickness in the Australian community, changes were underway in relation to provisions for the chronically ill and disabled. However, while Cumpston advocated bringing the chronically ill within the ambit of medical work and research, in Victoria, the trajectory of developments in the twenties and thirties was to remove these patients out of the centre of medical work – the general hospital – into the non-medical environment of benevolent care. Cumpston’s principal concerns were to maintain the ‘efficiency’ of the Australian population. In 1920s Victoria, the principal concern was to contain the cost of providing care for the chronically ill, and to ensure the required turnover of patients was maintained in the general hospitals so that they functioned efficiently as medical training schools and research facilities.30
30 Y. Collins, ‘The Provision of Hospital Care in Country Victoria 1840s to 1940s’, PhD Thesis, University of Melbourne, 1999, p.226.
78 Since mid-nineteenth century in Victoria, charitably minded citizens, doctors and the colonial/state government had joined forces to provide institutional care for the sick poor in the form of hospitals. Their activities led to a proliferation of institutions, especially in the metropolitan area, which formed the basis of a system of hospital care aimed at the different needs of various sections of the community.31 A parallel development, although less specific in its organisation, was the provision of accommodation for the incurable, the infirm and the dying, unwelcome in the voluntary hospitals because their needs were indeterminate, but who had nowhere else to go. The benevolent asylums took on this task as one aspect of the range of needs they attended to for those impoverished Victorians who called upon their assistance.
The benevolent asylums, established in the large Victorian provincial cities and in Melbourne in the course of the 1850s, also included the provision of some medical care for their charges.32 From its beginning in the 1850s, the Immigrants Aid Society for the Houseless and the Destitute included infirmary wards in its St Kilda Rd Home. The Society, set up by philanthropic Melburnians to provide indoor and outdoor relief for those newcomers to the colony who did not prosper in the gold-rushes, was prepared to provide shelter for indigent patients discharged as incurable from the Lying-In (Women’s) and the Melbourne hospitals. In 1862 the infirmary could accommodate 62 inmates, many of them from the Melbourne Hospital. In the face of the demand for long term care, the Society had to relax its rule of not assisting those who had resided in the
31 For example, the Melbourne Hospital opened in 1848 (adding Royal to its name in 1935), K. S. Inglis, Hospital and Community: A History of the Royal Melbourne Hospital, Melbourne University Press, Carlton, 1958; the Homoeopathic Hospital (later Prince Henry’s) in 1869, J. Templeton, Prince Henry’s, The Evolution of a Melbourne Hospital, 1869-1969, Robertson & Mullens, Melbourne, 1969; the Women’s Hospital in 1865, J. McCalman, 1998, op. cit.; the Alfred Hospital in 1870, Mitchell, op. cit.; also in 1870, the Children’s Hospital, P. Yule, The Royal Childrens Hospital, A History of Faith, Science and Love, Halstead Press, Rushcutters Bay, N.S.W, 1999; in 1893, St Vincent’s Hospital, Egan, 1993, op. cit.; and in 1899, the Queen Victoria Hospital for women and children, E. Russell, Bricks or Spirit?, The Queen Victoria Hospital, Melbourne, Australian Scholarly Publishing, Melbourne, 1997; and the Queen’s Memorial Hospital for Infectious Diseases (Fairfield) in 1904. 32 Cage, op. cit. Chapter Three. Benevolent asylums were situated at Ballarat, Bendigo, Castlemaine, and Beechworth. In Melbourne, they were the Home run by the Immigrants Aid Society and the Melbourne Benevolent Asylum; Dickey, 1977, op. cit. pp.54-55; S. Swain, ‘The Victorian Charity Network’, PhD Thesis, University of Melbourne, 1977, a study of the ‘voluntary principle in charity’ on a scale never achieved in Britain where the model was conceived. For a comparison with the approach in New South Wales see Dickey, 1980, op. cit. The government there played a more direct role in relieving poverty by taking responsibility for providing as well as funding institutional services, p.46-47.
79 colony for longer than two years.33 Its companion institution, the Melbourne Benevolent Asylum, also provided medical care of a quality to induce the indigent from country areas to bypass their local benevolent asylum and apply for assistance there.34 In 1882 the Austin Hospital for ‘incurables’ was established, also as a charitable venture.35
Up to the end of the nineteenth century, when surgery became safe, less painful and more popular, there may have been little to distinguish the wards in the hospital from the infirmary section of the benevolent institutions.36 The introduction of surgery however, had the effect of reinforcing the aim of the committees of management and their medical staff, to maintain the voluntary hospital as a place for short-term treatment. In addition, the emphasis on provision for the poor diminished, as hospital care in sickness became more acceptable to all social classes.37 With these changes in hospital practices, the infirmary wards of the benevolent institutions became even more closely associated with long-term sickness and poverty. Certain common attributes remained however: benevolent asylums and hospitals were managed by autonomous committees elected from subscribers, and both were increasingly dependent on government subsidies.38 Although the benevolent asylums were set up with a system of public subscriptions, from the very beginning these were inadequate. As in the case of the voluntary hospitals, the colonial/state government, became the ‘chief subscriber’ to the benevolent asylums.39
33 Uhl, op. cit. p.9. Uhl notes that the Society’s home was used as a hospital for three years before the Lying-In (Women’s) Hospital was opened, Note 6, p.221. 34 Kehoe, op. cit. p.32. 35 E. W. Gault & A. Lucas, A Century of Compassion, A History of the Austin Hospital, Macmillan, 1982, South Melbourne, 1982. 36 In some country districts the local hospital combined both functions although their limited facilities meant that their services were more oriented to outdoor relief, Cage, op. cit. p.33. This dual role was recommended by a Royal Commission into the provision of services for the poor and the sick in Victoria in 1870 and it was a condition of municipal or state government support that district hospitals were required to undertake both functions. M. Ronaldson, ‘The Development of Social Services in Victoria’, MA Thesis, University of Melbourne, 1948, p.156. 37Inglis, op. cit. p.172-3. 38Swain notes that the committees in the benevolent institutions were usually self perpetuating bodies whose management decisions were approved at the annual general meeting of subscribers. Swain, op. cit. p.45ff. 39 In relation to the voluntary hospitals, Inglis, op. cit. p.170-171, Mitchell, op. cit. pp.68- 74 and in relation to the benevolent asylums, Cage, op. cit. Appendix 5. In Victoria, Kennedy notes, the state assumed direct responsibility for the insane and inebriate asylums, the least appealing class of needy. The benevolent asylums satisfied a need that fell somewhere between the least appealing – the insane, and the most appealing - modern hospital services. R. Kennedy, ‘Poor Relief in Melbourne: The Benevolent Society’s
80
In the course of the 1920s the relationship between the infirmary wards of the benevolent homes and other types of hospital provision in the State became more clearly defined. This clearer definition did not arise, however, from any specific form of activity focused on these institutions. It was rather a side-effect of steps taken on one hand, by doctors to cultivate a hospital environment they believed to be conducive to the highest quality medical work, and on the other, of steps taken by the State government to regulate its funding of hospital and welfare services. As a consequence different levels of hospital care emerged: care during episodes of acute illness or injury in the large public teaching hospitals, convalescent in designated wards or institutions; and long-term care in the benevolent asylums.40 The differentiation of hospital care was not accompanied by a similar differentiation in the scope of medical work; the area of chronic care was designated as such by its exclusion from active medical intervention. It was associated with palliative care, overseen by a medical officer and provided under the auspices of charitable bodies.
In view of its increasing contribution to the funding of hospital services, the State government in Victoria, moved to regulate the activity by establishing the Charities Board in 1924.41 The Board consisted of a number of part-time members, representatives of hospitals’ associations and the committees of management of subsidised institutions. The Secretary to the Board was the only permanent official, a public service officer whose role was to act as intermediary between the Board and Treasury, which provided the funds the Board distributed.42 If the structure of the Board implied any cohesion amongst the various hospital committees, it is quite misleading. The formation of hospital associations
Contribution 1845 –1843’, Journal of the Royal Australian Historical Society, vol 60, pt4, 1974, pp.256-266. 40 A small private hospital industry had also emerged around the city and suburbs, by 1920, many of them established by nurses returned from service during the First World War. Where there were 476 of these in the 1920s, of which 195 had less than five beds, by the late forties there were about 266 with a maximum capacity of 4,357 beds. R. Inall, State Health Services in Victoria, Occasional Monograph, No 4, Department of Government and Public Administration, University of Sydney, 1971, p.61. In the country the Bush Nursing Hospital system provided a system of paid hospital services, subsidised by the State government. So long as patients could pay for their care, their needs were not distinguished in this fashion, see Collins op. cit. 41 Inall, op. cit. p.40-42. 42 Mr. C. L. McVilly occupied this position for the duration of the Board’s existence until the late 1940s. Gillespie notes that in this position he was considered to be the most powerful health administrator in Australia. Gillespie, op. cit. p.62, pp.204-206.
81 was a device adopted by the State government to oblige these disparate and autonomous entities to cooperate in the most minimal fashion. The Board itself had no power to compel hospital committees of management to take any particular course of action although there was some limited scope in the allocation of funds.43 The constitution of the Board by members of the very committees that the government sought to restrain suggests that the condition that called for the establishment of the Board – namely the autonomy of committees of management – was extended into supervising the allocation of funds. However, although the Board, as Ken Inglis notes, did not operate as an instrument of the State, neither was it a mere instrument of the institutions. It could be just as critical of one as of the other.44
The measures adopted by the Board reflect a concern with restraining expenditure, not with the provision of services.45 One such measure was the introduction of the factor of average length of patients’ stay in hospital into the estimation of an individual hospital’s subsidy.46 Another measure to minimise patients’ length of stay made the Secretary to the Board intermediary in the transfer of those patients who were medically certified not to need the level of care provided in the public hospitals into other
43 L. Gardiner, Hospitals in Association, A History of the Metropolitan Hospitals Associations 1918-1974, Mount Eagle Publications, Australia, 1977, ‘Origins’, p.1. 44 Inglis, op. cit. p.184. The administration of hospital services was indeed a fragmented process. The Department of Health was itself directly responsible for some institutions – tuberculosis sanitoria and the Cancer Institute, Inall, op. cit. p.27ff. Walker notes that much of the expansion of hospital services during the 1920s, was possible because of the fund raising capacity of committees of management. Having increased their services, hospital committees of management then called for an increase in funding from the State government. The establishment of the Board may be seen as a case of the State government trailing the committees of management as they set an expansionist agenda. C. Walker, ‘The Emergence of the Hospital System in Melbourne: 1846 to1975; PhD Thesis, La Trobe University, 1994, p.194. 45 In refraining from being involved in the actual provision of hospital service, the Victorian government, and to a lesser extent the government of New South Wales stood out amongst the states. In states without an affluent middle class to support charitable ventures, the colonial-cum-state governments played a more prominent role in the provision and control of hospital services. Even in New South Wales, a Labor government elected in 1910 began to take a more instrumental role in the provision of hospitals. Gillespie, op. cit. p.60ff, summarises briefly the activities of the states in this respect in the early decades of the twentieth century. See also B. Dickey, ‘The Labor Government and Medical Services in NSW, 1910-1914’, Historical Studies, vol 12, no 45, 1967, pp.541- 555, and J. Bell, ‘Queensland’s Public Hospital System: Some Aspects of Finance and Control’, in J. Roe, ed, Social Policy in Australia, Some Perspectives, 1901-1975, Cassell, Australia, 1976. 46 This approach was not altogether novel. It had been first taken in 1860 when the State government decreed that the average length of stay in hospital was to be no more than 25 days, when this was exceeded the grant was reduced. Mitchell, op. cit. p.9.
82 institutions.47 Country hospitals and the infirmary wards of the benevolent asylums were considered to provide a level of care more suited to the needs of such patients.48 In this manner the infirmary wards of the benevolent asylums took on an administrative significance that confirmed their role as chronic hospitals in the State’s hospital system.
The emerging role of the benevolent asylums as chronic hospitals became more clearly demarcated in the mid 1920s, when the Charities Board acquired wards no longer needed by the Repatriation Department in the No 11 Army General Hospital at Caulfield. The intention was to use these wards for patients, principally from the Melbourne Hospital, but also the other metropolitan teaching hospitals, who were deemed convalescent.49 The category of convalescent included patients who had had surgery or whose treatment for medical conditions would not exceed two months. It excluded those with long-standing and incurable conditions, malignant disease or disability related to tuberculosis or spinal injury.50 Acquisition of the wards at Caulfield meant that the Melbourne Hospital finally received a response to a request it had made to the State government in every accommodation crisis since the 1860s, for ‘convalescent’ beds where patients could be transferred after treatment until they were fit to be discharged.51
Another source of non-acute hospital beds was found in the After Care Hospital in Collingwood. The Melbourne District Nursing Society,
47 These patients could not afford to pay for their care. Some because of outright poverty, others because they had exhausted their resources in private hospitals and rest homes. Public hospital care was means tested until the Chifley government introduced a subsidy payable to the states on the condition the fees for public wards were abolished in 1945. Means-tested fees were reintroduced in the early 1950s when the Liberal-Country Party Coalition government introduced the system of publicly subsidised, private, voluntary hospital and medical insurance, Kewley, op. cit. p.353-354. 48 The measure was presented to country hospitals in danger of closing because of insufficient patient numbers, as a means of remaining in operation. Although transfer was presented to patients as a voluntary matter, they were subject to considerable pressure to comply even though it often meant moving to areas that were remote and far from families and friends. Collins, op. cit. p.182, p.207-208. In Chapter 6 Collins outlines the effect of such transfers on the hospitals and some of the patients involved, during what she describes as one of the less notable events in the history of the administration of hospital services in Victoria. 49 VPRS 4523/P1/51/475; Mitchell, op. cit. footnote 61, p.272. 50 B. Ford, The Wounded Warrior and Rehabilitation, The Alfred Healthcare Group, Caulfield General Medical Centre, 1996, p.88-89. 51 Inglis, op. cit. p.89.
83 initially set up in the late nineteenth century by philanthropic Melbourne women, to provide nursing care for sick mothers and their babies at home, enlarged the scope of its operations by building the After Care Home. It opened in 1926 to accommodate the Society’s patients who were fit enough to leave hospital but not to return home.52 Less than ten years after it opened however, the Home was renamed the After Care Hospital and accepted patients from the Melbourne Hospital who were considered to need nursing care but not the sophisticated medical services of that institution.53
Organising Medical Work While the Charities Board attempted to rationalise the use of acute hospital beds on the grounds of cost, another process of rationalisation was underway at the Austin Hospital. The changes that were set in train at the Austin from the late 1920s provide an insight into the reverse side of the process taking place in the benevolent asylums, a process that underpinned a growing differentiation between acute and chronic illness in the work of medical practitioners. The Austin, as noted above, was originally established, as a philanthropic enterprise, to provide care for the dying and incurable patients who were unwanted in the general hospitals. The reorganisation set in train at this time entailed the removal from the hospital of a particular segment of ‘incurables’ with the overall effect of reducing the numbers of beds available for their care. Rupert Willis, whose ambition to work in hospital pathology at the end of his medical training, had been frustrated by lack of opportunity, was appointed medical superintendent in 1926, after a period of general practice in Tasmania.54 For the twenty years prior to his appointment, the matron of the hospital had supervised patient care and one of the first steps he took was to initiate a through medical examination of all patients.
52 N. Rosenthal, People – Not Cases, The Royal District Nursing Service, Nelson, Australia, 1974, p.71ff. 53Ibid. p.103-104. 54 R. A. Willis, ‘Recollections of Medicine at the Austin Hospital: Heidelberg in the 1920s’, MJA, vol 1, 1979, pp.15-17. Willis was one of the ‘notable company’ amongst whom Macfarlane Burnet graduated, and his activities at the Austin were the beginning of a distinguished career in his chosen field of pathology, C. Sexton, Burnet, A Life, 1862- 1962, Oxford University Press, South Melbourne, 1999, p36. When Willis wrote this article he was Emeritus Professor of Pathology at the University of Leeds, England.
84 Willis’ investigation revealed a ‘treasure house of largely unexplored pathology’ but at the same time it also revealed many patients whose conditions were not so interesting. Some had been admitted with an incurable disease in younger days and had grown old there, others had come more recently following a stroke, for example and there was a long waiting list of such applicants.55 On the basis of his examinations Willis began to separate out those patients whose conditions could be identified in pathological terms from those he described as needing nothing more than ‘a home to live in and nursing care’. Willis’ reorganisation did ensure a place for patients doctors wished to exclude from the convalescent wards of Caulfield Hospital – that is those with malignant disease, tuberculosis and spinal injury – however, he also made it clear that other patients were considered ‘beyond the pale’ of active medical work. These old people, incapacitated by stroke or other conditions linked to old age, were shifted to Cheltenham Old People’s Home, located many miles distant from the Austin.56
In 1943 an officer of the Walter and Eliza Hall Trust Fund wrote to the Secretary to the Charities Board, C. L. McVilly, asking about the status of the benevolent asylum at Bairnsdale.57 McVilly replied that the infirmary sections of the benevolent institutions were ‘akin to hospitals’ because they accommodated many ‘cases’ that would otherwise have been in the general hospitals. However, while there may have been little to distinguish infirmary wards from those in the general hospitals earlier in the century, by mid-century they were distinguished by being classified as a ‘home’ rather than hospital.58 The change in the meaning of the word
55 Willis, op. cit. p.15-17, Gault & Lucas, op. cit. p.116ff. 56 Willis’s decision to do this attracted public criticism in the newspapers. Apart from cutting down the beds available for the infirm aged, the friends and families of patients who lived near the Austin, north-east of the city, would have found it an interminable and perhaps impossible, journey to visit them at Cheltenham in the south east. The distinction Willis made, between patients suitable for the Austin and those needing ‘home care’, was, even at that time, not so clear. In the late 1920s, cancer patients from the Austin were removed to empty wards at the Bendigo Benevolent Home with the Charities Board funding the necessary renovation of this accommodation, F. Cusack, Candles In the Dark, A History of the Bendigo Home and Hospital for the Aged, Queensberry Hill Press, Carlton, Victoria, 1984, p.159. 57 VPRS 4523/P1/91/888; when the District Hospital at Bairnsdale moved to new premises in the 1940s, the vacated building became the Gippsland Benevolent Home. The committee of management there had, it appears, written to the Trust requesting assistance. 58 The Bendigo Benevolent Asylum and Lying-In Hospital was renamed Bendigo Benevolent Home in 1937. In the early 1950s, the provision of Commonwealth subsidies for these activities, led to the general substitution of the term ‘home’ for asylum, possibly
85 infirmary illustrates the role of the benevolent institutions within the overall system of hospital services in the State. In the nineteenth century, and perhaps early in the twentieth, the word was used to designate any institutional setting for the care of the sick. By the 1940s the word infirmary referred to an ‘institution for the housing and maintenance and care of needy, infirm patients with chronic disability’, most of whom were elderly simply because infirmity increases with age.59
The medical work of caring for infirmary patients was quite distinct from that done in the general hospitals. In the infirmary ‘conditions were laissez-faire – feed them, bed them, and treat symptoms as they arose’.60 This approach was the opposite of the highly interventionist response to disease and disability in the hospitals. It was difficult however, in the everyday work of doctors in the public hospitals, to maintain the distinction between acute and chronic patients. From the 1920s into the 1950s (and indeed thereafter), the files of the Charities Board and its successor body the Hospitals and Charities Commission are filled with the complaints of doctors about the problems they faced in discharging patients who needed medical and nursing care but who had nowhere else to go.
Benevolent Care By the early 1950s the state government subsidised the following benevolent institutions; Bendigo Benevolent Home, the Alexander Home at Castlemaine, the Gippsland Benevolent Home at Bairnsdale, Cheltenham Old People’s Home, Mount Royal in Parkville, the Ovens and Murray Home at Beechworth, and the Queen Elizabeth Home at Ballarat.61 The majority of inmates in these institutions were elderly although younger people with incurable conditions and disabling injuries from
as Kewley notes, because of the growing unacceptability of the term ‘asylum’, Kewley, op. cit. p.305. 59 S. Sax, ‘Need for Infirmary Accommodation’, The Australian Journal of Social Issues, vol 3, no 1, 1967, p.33. 60 A. McCutcheon, ‘Retrospect’, MJA, vol 1, 1958, pp.272-275. 61 Annual Report, Hospitals and Charities Commission, 1955. Mount Royal had four infirmary wards, each with 53 beds, Cheltenham Old People’s Home provided a similar number, including two wards set aside for diabetic patients from Prince Henry’s Hospital. The two largest country institutions at Ballarat and Bendigo, each accommodated around four hundred in their infirmary wards.
86 accidents could also be found in the wards.62 As well as the infirmary wards where the aged predominated, other sections of the homes accommodated old people who were able to get about but who had entered the home to avoid being in the position of needing assistance at a later date.
The homes had begun by offering asylum – ‘indoor relief’ as it was termed - to distressed individuals, male and female, of all ages, but unlike similar institutions in other parts of the world there were, in general, more old men than old women. In the late nineteenth century the proportion of men in the Victorian population was greater because of the earlier influx of gold seekers who were most often single men. Dependent as they were on their physical resources to earn a living, increasing age, and perhaps a lifetime of itinerant labour, they had nowhere else to go except the benevolent asylum.63 As they became more dependent, they moved from the ambulatory sections to the infirmary wards. The lives of many of the men accommodated in the benevolent homes, well into the 1950s, had been shaped by poverty in childhood, and war and depression in adulthood. After a peripatetic adulthood they went into old age without ever having put down roots or established the relationships that may have sustained them in their old age.64
By the early 1950s, women had come to outnumber men in the Victorian population over the age of 65 but they were not so prominent amongst the inmates of the benevolent homes.65 The homes continued to provide a refuge for single men without family or material resources, a group similar to those who sought admission in the 1890s. Women were more likely to
62 The introduction of a State sponsored scheme for compensating injured workers in Victoria in 1914 meant that patients in this category admitted to Mount Royal provided a source of income not available for other categories of patient. The various workers’ compensation schemes in the states, from their inception in the early 1900s, are briefly described in the introductory pages of the Report of the National Committee of Inquiry, Compensation and Rehabilitation in Australia, Chairman W. O. Woodhouse, 1974, AGPS, Canberra. As Caulfield Convalescent Hospital and the After Care Hospital began taking convalescent patients, Mount Royal was more often allocated those least likely to achieve any degree of recovery, Uhl, op. cit. p.134. 63 Cage, op. cit. p.75. 64Old people in the country particularly, if they had no resources of their own, had to apply for admission to homes many miles from their own communities. The home at Ballarat for example served the whole of north west Victoria, A. J. & J. J. McIntrye, Country Towns of Victoria, Melbourne University Press, Melbourne, 1944, p.135-136 65 Table 3, p.19, A. H. and G. N. Pollard, ‘The Demography of Ageing in Australia’, in Towards and Older Australia, Readings in Social Gerontology, ed A. L. Howe, University of Queensland Press, Queensland, 1981.
87 have family to help them and may have been more welcome than men in the church homes that also provided accommodation for elderly people at this time. In general, the benevolent homes were impressive buildings, located at some distance from the surrounding community but prominent on account of both their situation amidst extensive gardens and their grandiose style of architecture. They stood as monuments, testifying to the extent of a community’s care for its aged members. Many of the amenities the homes boasted - concert hall, library, a small shop to provide cigarettes and sweets - were provided through the activities of ladies’ auxiliaries, and other community associations such as local Rotary groups.
The homes represented a conception of old age as a time of retirement from active life and relief from responsibility, entailing a duty of care on the part of the family or, in its stead, the community through institutions such as these. The importance of their role was attested by the size of their populations - both Mount Royal and the Cheltenham Old People’s Home in the metropolitan area accommodated between six and seven hundred inmates in total - and in the size of their waiting lists. The waiting list in particular was an ever-present inducement to the committees of management to expand their range of activities and intensify fund-raising activities.66 The gradual emergence of the role of de-facto chronic hospital was not accompanied by any diminution of the role of the institution as ‘home’ for the aged, and accommodation for ambulant old people expanded alongside the wards for the infirm.
In keeping with their home-like character, the position of medical officer in these institutions was not a significant one, either in relation to the home itself or in the medical profession at large. It was filled by a local general practitioner, often in combination with private practice. The medical officer had no formal role in the management of the institution. At meetings of the committee of management he, rarely she, may have been invited to present a report on the health of his charges and then leave. Conditions of employment were negotiated between doctors and the individual institutions; in some cases this meant appointment to the
66 It was the practice, one that persisted into the early 1970s, for elderly people without much in the way of resources, to put their names on the waiting list to avoid the situation of needing care and not being able to get it. Many in this group were admitted when their names were at the top of the list simply for reasons of security.
88 position of medical superintendent with the provision of a house for the doctor and his family, but not in others. Up to the early 1950s, in general, the one medical officer had the responsibility of providing medical care for all inmates.67
In his survey of the lives of old people in Victoria in the early 1950s, Hutchinson noted that neither aspect of the dual role of the institutions was performed adequately.68 The standard of care provided in the infirmary wards was low and the lives of the ambulatory inmates were regulated by same routine as that prescribed for the bedridden. There was little opportunity or encouragement for these more able individuals to take part in any kind of activity. A visitor to one of these institutions was likely to be ‘overwhelmed by a terrifying atmosphere of boredom’. There was in fact nothing to do apart from helping in the daily routine, preparing bread and butter for tea, laying tables, and assisting in the care of the bed-bound. In the infirmary wards, many of them accommodating fifty or so people, aligned in rows of beds placed so it was possible to fit in as many as possible, an atmosphere of ‘cold severity and colourless cleanliness’ prevailed.69 Nursing care was provided by untrained attendants, or the more able inmates, attendants were always in short supply because the pay was low and the work constant and arduous.70
Fleur Finnie went to Cheltenham Old People’s Home in 1940 because she’d heard jobs were readily available there and she’d had failed her Intermediate Certificate, the passport to her desired career as a kindergarten teacher.71 She was frightened of men and had asked not to be
67 For example the Melbourne Benevolent Asylum, later called Cheltenham Old People’s Home, and then Kingston Centre, provided the position of medical superintendent, and it was held by Dr Carlisle from 1935 to 1960, at Mount Royal this position did not exist. 68 B. Hutchinson, Old People in a Modern Australian Community, Melbourne University Press, Carlton, 1954, p114. In 1950 the Rotary Club of Melbourne sponsored the formation of a Citizens’ Committee made up of representatives of the churches and other philanthropic and community groups working to provide services for old people. The Committee decided to conduct a survey of the ‘extent and nature of the problem of old age in Victoria’ as the basis for coordinated measures to address it. An English social investigator, Bertrand Hutchinson, was commissioned to undertake the study, which he did with the assistance of the Department of Social Work at the University of Melbourne. 69 Hutchinson ibid. p.114ff. 70In August, 1949 the manager of Mount Royal Home and Hospital for the Aged noted that it was a good idea to mix the ambulant and bedridden patients because ‘… a patient who could move around could be given the interest of doing jobs within his capacities and assisting nursing staff.’ However he also noted that a growing number of applicants for admission were not fit enough to do this. VPRS 4523/P1/260/2242. 71 F. Finnie, Don’t Stand on the Grass, Vista Publications, Melbourne, 1996, p17-18.
89 put on a men’s ward but at six o’clock on her first morning, she found herself in a large ward facing ‘four rows of beds’ along the length of the ward, every one of them occupied by a man. There were no curtains or screens and these men were being washed as they lay naked, the bedding pulled to the foot of the bed and their nightgowns removed. It was some time before she became accustomed to the smell of urine and faeces that pervaded the ward. Breakfast was served by two cleaners who then also helped to feed the helpless inmates. They handed around porridge served on enamel plates with a small amount of milk and sugar. Because there were no backrests on the beds and pillows were scarce, many of the men were obliged to eat their meals lying down with the plates on their chests. The tea came already made up with milk and sugar, too bad for those who didn’t like it that way.72
The benevolent homes also had their own ideas about acceptable patients. They would not keep individuals who were disruptive and would not accept mentally disturbed individuals – in some cases there may have been a clause specifically excluding this group in their statement of purpose for registration as a charity.73 Mentally disturbed old people were not wanted anywhere and although doctors in the Mental Hospitals may have doubted that certification as insane and incarceration was in their best interests, there was usually no other choice. An incident in 1925, at Mount Royal (then called Victorian Homes and Hospital for the Aged), serves to illustrate the sad condition of these feeble old people. A special court was convened at the hospital with a Justice of the Peace presiding and two doctors in attendance to certify that the patients in question were indeed insane. They were then conveyed, with police escort, to Kew Mental Hospital.74 The Inspector General of the Lunacy Department, Dr Ernest Jones, complained about this ‘inhumane’ action to the Inspector of
72Ibid. p.21. Finnie noted that the shortage of workers in the wards became more acute in wartime. She was told that all the cleaners in her first ward were prisoners on life sentences who, because of the good behaviour, had been discharged after thirty years in goal. They lived at the Home, accommodated in the cleaners’ dormitory, receiving their meals and five shillings a week in wages, p.25. 73 VPRS 4523/P2/8283. For example Mount Royal had a by-law forbidding the admission of the insane – the only form of classification at the time to distinguish mentally confused old people from other infirm aged people. 74 VPRS/P1/153/1493.
90 Charities, emphasising the point that these people could be cared for in a benevolent home, in a ward set aside for the purpose, by trained staff.75
Some of the homes, particularly the smaller country institutions that sometimes found it difficult to keep up their numbers, did accept patients from the Mental Hospitals who had reached a stage where the frailities of old age had overtaken mental illness, and who were considered to be manageable in the benevolent home setting. The advantage in taking these patients was that their board and keep was paid for out of the Treasury allocation for mental hospitals.76 The Castlemaine Benevolent Home was happy to accept these quieter patients but in the opinion of the committee, ‘much of the work can be carried out efficiently by women trained in a lesser degree than that demanded of a certificated nurse’. Dr Jones went on to say in his letter, that out of 809 admissions to Kew Mental Asylum in 1924; the condition of 102 of these individuals was attributable to changes associated with ageing. While technically it may have been possible to certify these old people as insane, they were in fact ‘hospital cases needing special care for the aged’, and this, he pointed out, was in fact the stated purpose of the benevolent homes. It was to be another sixty years and more, before mentally confused old people were provided with care suitable to their needs and over the intervening years Dr Jones’ successors reiterated his remarks at regular intervals.
When the issue of a medical role in relation to old age infirmity was first raised in the mid-1950s, the benevolent institutions were caught up in an unsystematic and fragmented system of hospital provision in the State. They had become repositories for those chronically sick and infirm patients who had nowhere else to go and the practice of sending patients to these institutions who were unacceptable in the convalescent wards ensured that most of these were elderly and infirm. The institutions were part of a state wide but uncoordinated, process in which two levels of
75 Ibid. 76 Because the Commonwealth viewed the upkeep of the inmates in the benevolent and mental asylums as the responsibility of the States, admission to one of these institutions was grounds for exclusion from eligibility for the Age Pension. If an individual was in receipt of a pension before admission, it was stopped. In 1923 and again in 1947 changes were made in respect of the inmates of benevolent homes but it was not until 1966 that the Commonwealth responded to representations from state ministers of health and agreed to pay pensions to eligible mental hospital patients. Kewley op. cit. p.120, p.304-305 and p.422-423.
91 hospital services emerged. One level provided acute care, where the requirements for practising and teaching a laboratory based medicine dominated; the other, a combination of convalescence and custodial care defined principally in terms of its lesser cost, not the specific needs of patients in this category nor the specific skills of medical staff. As hospital services provided by voluntary groups, although publicly funded, the benevolent institutions, were incorporated into the State’s hospital system in the course of pursuing their own particular objectives. The predominance of old people amongst those accommodated in the infirmary wards reinforced the other function of these institutions – that of ‘home’ for the aged.77
Medical Responses to Old Age Infirmity in Postwar Victoria By the early 1940s, when the first signs of professional interest in old age infirmity began to appear in the pages of the Medical Journal of Australia, the provision of institutional care was firmly established as the appropriate response to old age infirmity, in the minds of Victorians, medical practitioners included. A few doctors did question this approach either directly or indirectly, and as they did so social medicine once again provided a source of ideas. In what appears to be the last gasp of the national efficiency movement, C. V. Crockett, described as Director of the Department of Medical Sociology and Research in the New South Wales branch of the British Medical Association, advocated a sociological approach to the management of an ageing population.78 The rising numbers of older adults in the Australian population, Crockett wrote, called for attention to the degenerative diseases characteristic of ageing
77 In their application for registration as a charity with the state government, which was updated periodically, these institutions had to state their objectives. In 1923, Mount Royal, then known as Victorian Home and Hospital for the Aged, for example, listed relief of the aged and infirm, VPRS P2, /8283. 78 C. V. Crockett, ‘The Shift to Higher Age Levels in Australia and the United States: Its Sociological and Medical Interest’, MJA, vol 2, 1943, pp.473-476. Crockett’s article is the only mention of medical sociology in the Journal, apart from an editorial in 1941 which suggested the formation of a special interest group devoted to the ‘study of medical sociology’ to enable doctors to contribute productively to discussions then in train regarding postwar reconstruction. The editorial was prompted by papers read at a meeting of the Victorian branch of the BMA in that year. Dr. J. Dale, medical officer of health for the City of Melbourne had called for social reform ‘not of any particular brand’ to address the problems of sickness he found amongst the deprived residents of Melbourne, MJA, vol 2, 1941, p.143-144 and pp.135-140. There does not appear to be any record of Crockett or his group in NSW. The tone of his article echoes discussions earlier in the century when infant mortality and childhood sickness were posed as problems of national concern, P. Mein-Smith, Mothers and King Baby, Infant Survival and Welfare in an Imperial World: Australia, 1880-1950, Macmillan, Basingstoke, 1997, pp.30-36.
92 adults and he described this work as geriatrics. In addition, he encouraged governments in Australia to emulate the example of the United States and fund research into the normal ageing process so that preventive measures could be better informed through the science of gerontology. Overall, these disciplinary endeavours would provide the knowledge to address a problem Crockett posed in an idiom characteristic of postwar social medicine in Britain; ‘Should society be content with improving facilities for the care of the aged – and there is much to be done in this direction – or should it also interest itself in better utilising the capacities of the ageing?’79
In 1946, an anonymous editorial advocated a more pragmatic approach. The editorial cited the example of Marjory Warren, who, together with a small group of like-minded colleagues, developed a model medical service directed towards the needs of old people who were at risk of needing custodial care.80 The ‘geriatric service’, as this model came to be known, was also a pragmatic response on the part of these doctors to demands for admission to the long-term care wards in the hospitals they managed.81 The ‘geriatric service’ as a response to the demands of the moment did, in fact, put into practice the social medicine model, as medical treatment was aligned with welfare measures in an acknowledgment of the part played by social conditions in sickness and disability in elderly people.82 Further, because the group of patients for whom geriatric services were developed often suffered from multiple disease conditions as well as the effects of age-related deterioration, the aim of medical treatment was the re- establishment of social function and not simply the eradication of disease.83
79 Crockett exemplified another aspect of the social medicine movement also in that he/she posed the problems presented by increasing numbers of elderly people as a problem of ‘national efficiency’. The program he proposed brought together two lines of development that were present in the twenties and thirties in Australia. Cumpston’s effort to establish a national hygiene through the Department of Health and the parallel development in the National Efficiency Movement, Rowse, op. cit. p.44ff. 80 ‘Current Comment’, MJA, vol 2, 1946, p.459-460. 81 Warren, Lionel Cosin and Eric Brooke, all with responsibilities for managing municipal hospital beds, being either medical superintendents or deputies, independently developed methods of dealing with the demands made on their services by infirm old people and their families who looked to hospital admission and long term care as a solution to their problems, Howell, 1974, op. cit. 82 M. Warren, ‘Activity in Advancing Years’, British Medical Journal, vol 2, 1950, p.922. 83 M. Warren, ‘Care of the Chronic Aged Sick’, The Lancet, vol 2, 1946, p.841.
93 The principles underlying the geriatric service and the medical approach to the treatment of old people at risk of needing custodial care were publicised in a report by the British Medical Association in 1948.84 The report noted that these individuals should be treated in a special department of the general hospital to ensure that the same investigative resources were brought into use as were available for other patients, with the aim of identifying treatable conditions. The same provision applied to the restorative treatment given by occupational and physiotherapists, aimed at making the most of any capacity an individual had to be independent in the activities of everyday life. Neither requirement necessarily involved any degree of specialist technical skill although overall, the application of conventional approaches to this group of patients did require a degree of clinical acumen achieved only through experience.85 The novelty of the approach advocated in the report lay in the application of generally accepted methods of treating disease and disability in adults to a group usually excluded on grounds of advanced age and, it should be emphasised, poverty. Warren’s more rigorous approach to the medical care of old people did entail a reversal of previous practices whereby old people who were unwell were routinely put to bed. She particularly emphasised the part played by activity in maintaining physical and mental well being in old people.86
The doctors who promoted the geriatric service did so in order to make a place in the acute hospital for a neglected group of patients. In doing so they shifted their orientation, apparently informally and as a practical response to the pressure of demand on their institutions, towards that of social medicine. In fact, the geriatric service highlights the association characteristic of social medicine, between humanitarian response to need and the efficient management of national resources. The service certainly provided medical treatment for a group previously excluded from active
84 M. Martin, ‘Medical Knowledge and Medical Practice’, Social History of Medicine, vol 7, no 3, 1995, p.447. 85 Warren wrote of ‘geriatrics’ as a medical specialty comparable to paediatrics. In her view the geriatric unit in a general hospital would provide the setting for undergraduate teaching, where students would not only be shown chronic cases but ‘see them under treatment and watch their seniors manage such cases from the beginning to the end.’ Warren, 1946, op. cit. However Martin makes the point that in the 1950s, when Victorians became interested in the geriatric service, the medical work of geriatrics could best be described as the medical treatment and appropriate dispersal of old people amongst a range of welfare services, Martin, op. cit. p.458. 86 Warren, op. cit. 1950, p.921-922.
94 medical treatment. At the same time it provided an institutional setting for the classification of dependency in elderly patients, and their distribution amongst a range of welfare services ranging from long term hospital care, to various types of assisted accommodation and domiciliary assistance. It was no coincidence that the BMA report publicising this classificatory system and its institutional setting was published as part of a larger report titled The Right Patient in the Right Bed.87
Coincidentally, around the time the report was published one of the earliest texts in postwar social medicine in Britain appeared, devoted to the topic of health and sickness in old age. J. S. Sheldon’s The Social Medicine of Old Age, was given an appreciative reception in the Medical Journal of Australia.88 Sheldon was commended for providing a ‘social biology’ of old age and providing insights into health and sickness in old people that were not available in a hospital setting. The study, a random sample of old people at home in the English town of Wolverhampton, illustrated the difficulties of categorising the condition of adults over the age of 70 according to standardised notions of what was normal.89 It also demonstrated that active social involvement played an important part in preserving good health and that in the elderly this state was best defined in terms of capacity for engaging in the activities of everyday life, rather than in terms of absence from disease. Not the least of Sheldon’s findings was that impediments to participation in everyday life, on the part of elderly people could be alleviated by simple measures – the provision of adequate spectacles, teeth, chiropody services, and welfare measures to assist people to overcome social and economic difficulties.
In the early 1940s in Britain social medicine emerged as a discipline with the aim of facilitating ‘progressive human social and biological evolution’,
87 Martin, op. cit. p.447, footnote 15. 88 J. S. Sheldon, The Social Medicine of Old Age, The Nuffield Foundation, Oxford University Press, London, 1948, reviewed under the heading, ‘An English Inquiry into the Health of Old People’, MJA, vol 1, 1948, p.797-798. 89 Sheldon believed his study confirmed John Ryle’s point that there was no normal versus abnormal in states of health, only points along a scale of normality, p.21. Canguilhem put the matter of ‘normality’ into perspective with the comment that ‘No environment is normal. An environment is as it may be. No structure is normal in itself. It is the relation between the environment and the living thing that determines what is normal in both. A living thing is normal in the true sense when it reflects an effort on the part of life to maintain itself in forms and within norms that allow for a margin of variation …’, ‘Normality and Normativity’, in A Vital Rationalist, Selected Writings from Georges Canguilhem, ed F. Delaporte, Zone Books, New York, 1994, p.354.
95 through the management of corporate welfare. Other Chairs of Social Medicine were established at universities in Edinburgh, Birmingham and Sheffield to provide the disciplinary material needed to educate doctors about disease in its ‘natural’ environment. Despite these successes attempts to insert social medicine into the medical curriculum in England at this time were not successful.90 In Victoria, despite the overall emphasis in postwar plans for developing research and medical training facilities focused on the biochemical model of disease, social medicine did influence the thinking of some medical practitioners.91 As in the 1920s and 1930s, it was an influence that existed as an undercurrent to other concerns but one that, nonetheless, did contribute to the climate of opinion in which the task of developing the State’s hospital services was addressed.
At the Clinical Research Unit located between the Walter and Eliza Hall Institute and the Royal Melbourne Hospital, the Director, Ian Wood, was interested in studying chronic disease. Following the example of Ryle at the Oxford Institute, Wood appointed a social worker to facilitate the inclusion of the ‘social’ element into research in the Unit. A more direct connection with social medicine was established when Eric Saint was appointed to a post in the Unit following his distinguished effort in the examination for membership of the Royal Australasian College of Physicians.92 With the encouragement of Wood, Saint investigated chronic disease in that ‘no-man’s land’ between ‘medicine and sociology’. In his view the ‘near perfection … achieved in modern surgical techniques’ and microbiology, had accentuated the sociological problems
90 Oswald, op. cit. 91 E.V. Keogh, ‘Fifty years of Medical Research in Australia’, MJA, vol 1, 1951, pp24-28, Keogh noted ‘Little investigative work has come out of the clinical schools’ because of lack of liaison between hospitals and universities where fundamental research was being done and lack of rewards. In giving the annual Halford Oration, shortly after his appointment as Professor of Physiology and Dean of the Faculty of Medicine, R.D. Wright included the ‘vast store of sociological knowledge which is the birthright of medicine’ in his call for the cultivation of academic skills in the medical school to develop and teach a ‘theoretical synthesis in medicine’, Wright, op. cit. p.639-640. 92 Saint’s achievement was notable not only because of the standard of his work, but also because he had studied for the College examinations while working as a medical officer for the Western Australian government in the isolated Pilbara region, R. B. Lefroy, On Good Doctoring, Eric G. Saint, Foundation Professor of Medicine, The University of Western Australia, Privately Published, Perth, 1998, p.6; E. G. Saint, ‘Reflections on Australian Medicine’, in Lefroy, ibid. pp.132-135; F. M. Burnet, Walter & Eliza Hall Institute, 1915- 1965, Melbourne University Press, 1971, p.40-42, p.148-149.
96 facing medicine.93 In addition to his work combining physiological studies into liver and pancreatic disease with studies of chronic alcoholism, Saint also studied a group of elderly patients at the Royal Melbourne Hospital, incorporating clinical, social, and psychological perspectives of these individuals in doing so.94
The focus on elderly patients in Saint’s research was not intended to promote the speciality of geriatrics but to highlight the point that sophisticated medical care was of no value while the conditions in which people became sick were ignored. The medical care of the elderly exemplified this situation in ways not so apparent with other adults. Moreover, because doctors in the hospitals and in the community, were beginning to treat increasing numbers of elderly patients, clinical philosophy needed to be clarified in order to provide balanced and effective medical services.95 Saint’s teaching duties during his time at the Clinical Research Unit gave him the opportunity to disseminate his ideas to both medical and graduate students.96 However his influence on Victorian doctors was cut short when he returned to Western Australia in the mid-fifties to set up a Clinical Research Unit at the Royal Perth Hospital and then, in 1956 to be appointed Foundation Professor of Medicine at the University of Western Australia.97
Eric Saint came under the influence of social medicine as he completed his medical training at Durham University in the early 1940s when met Sir James Spence, Professor of Child Health at Durham. Spence was renowned for the study known as the ‘Thousand Families Survey’ conducted in Newcastle during the Depression where he established the connection between social class, poverty, and sickness.98 Saint himself, illustrated the relationship between disease and environment in his first
93 E. G. Saint, ‘Social Perspectives in Medicine’, MJA, vol 1, 1955, p.161. 94 Saint, et al, op. cit. 1953. Saint’s work on alcoholism was also unusual at the time. Prior to this, at Burnet pointed out, heavy drinking had not been considered a suitable topic for erudite medical attention, Burnet, 1971, op. cit. 95 Saint et al, 1953, op. cit. p.763. This point was reinforced in a study he conducted in Perth, concluding that out of 250 new inpatients and 150 outpatients, medical staff at the hospital failed ‘to place about a quarter of our patients either in productive employment … or in living conditions which one could be confident would have no harmful influence on future progress.’ Saint, 1955, op. cit., pp.161-165. 96 Lefroy, 1998, op. cit. p.7, notes that Sir Charles Best, who discovered insulin, described Saint’s exposition at a clinical meeting at the Institute as one of the best he had ever heard. 97Ibid. ‘Introduction’. 98E. G. Saint, ‘Influences on Careers in Medicine’, in Lefroy, 1998. op. cit. p.102-103.
97 postgraduate study, on miner’s nystagmus, a condition in which a change in eye function was associated with a low level of lighting and psychoneurosis. John Ryle’s representation of social medicine as the rational discipline relevant to corporate welfare conveys a somewhat bleak humanism. In contrast, Saint and Spence show social medicine as a ‘vast social enterprise’ in which empathy and objectivity combine in a personal encounter between physician and the ‘sick man’.99
Macfarlane Burnet observed that, ‘I am certain that Saint’s work on these topics (alcoholism and the medical significance of old age), … played a large part in building up the continuing attitudes that have made him … one of the chief spokesmen for social medicine in Australia’. Burnet’s comment leaves open the question of the extent to which Victorian doctors were open to Saint’s influence.100 Indeed Burnet himself, despite being an avowed admirer of Sir James Spence, does not appear to have grasped the point of social medicine as a discipline. Many years after Burnet met Spence in 1948 when he attended the Sixth Australasian Medical Congress in Perth, Burnet described Spence’s contribution to medicine in terms of enabling medical practitioners to ‘teach more cogently and clearly about illness at it shows in the family’. The fact that Spence’s Thousand Families Survey highlighted the effects of social and economic conditions on the health of families is completely bypassed. Burnet then went on to comment that Spence, were he still alive, would be impressed with the extent to which the study of the family had been advanced through the science of genetics.101
Burnet’s comments suggest that despite his interest in disease in its ‘natural’ environment, he was unable to see beyond the medical
99Ibid. Giving this lecture, ‘Influences on Careers in Medicine’ in the 1960s, Saint noted there would probably not be a place for physicians such as Spence because the ‘cast of his mind was literary’ and possibly he would not have gained the four ‘A’ level passes in the physical and biological sciences that were then required for entry to the medical course. 100 Burnet, op. cit. 1971, p.149. The brief interlude in the 1950s in Melbourne, when social medicine received this much attention may be represented as a period in the shift in the mode of production of medical knowledge, from hospital medicine to laboratory medicine which took place in Australia long after it had occurred in Europe and America, N. Jewson, ‘The Disappearance of the Sick-man from Medical Cosmology, 1770-1870’, Sociology, vol 10, 1976, pp.225-244. 101 F. M. Burnet, The Thousand Families, A Tribute to Sir James Spence, A Lecture Delivered at the University of Southhampton, 1975.
98 materialism that underpinned his interpretation of disease. The appointment of a social worker at the Clinical Research Unit as a means of ensuring the incorporation of social factors in studies of disease, reflects the secondary position accorded to the ‘social’, even taking into account the lack of development in the social sciences in Australia at the time. The problem of re-integrating the social and medical elements in disease in the discipline of social medicine will be discussed in more detail in Chapter Four. The departure of Eric Saint appears to have brought to an end any local ventures in the discipline of social medicine although Burnet notes that Ian Mackay, who followed Ian Wood as Director on his retirement in the early 1960s, was also interested in chronic disease and its social components. Perhaps it was this interest that led Mackay to cultivate an association with near-by Mount Royal Hospital for the Aged and, in the late 1970s, accept a position as a member of the committee of the Mount Royal National Research Institute for Gerontology and Geriatric Medicine.102 By the late 1950s however, work in the Clinical Research Unit was more closely focused on the isolated, individual body in the study of autoimmunity, a shift in focus that Burnet suggests may have arisen from the conditions imposed by the National Health and Medical Research Council, in agreeing to continue funding for the Clinical Research Unit.103
Further indication of support for social medicine within the Melbourne medical world may be found in the decision J.S. Collings made to come to that city in 1953, to establish a form of general practice which exemplified the practical content of social medicine. Trained in the medical school at the University of Sydney, he believed, unjustifiably as it happened, that the medical school at the University of Melbourne may have been more receptive to his plans for education in general practice.104 Collings’ ideas on the funding and organisation of general practice and medical education, were originally stimulated by his experience in group general practice in New Zealand. They were developed further through research into general practice commissioned by the Rockefeller Foundation in the United States,
102 See chapter Six. 103 Burnet, op. cit. 1971, p.143-44. 104 R. Petchey, ‘ “A Man Ahead of His Time” – Joseph Silver Collings (1918-1971)’, Proceedings 6th Biennial Conference of the Australian Society of the History of Medicine,
99 and in England, by Sir William Jameson, Chief Medical Officer at the Ministry of Health. Jameson, as noted above was one of John Ryle’s associates in promoting social medicine.105
Collings believed that social medicine was the central pursuit of the general practitioner and he put his ideas into practice by establishing a health centre where the contributions of a range of health professionals were integrated into general practice.106 He chose a location in Richmond, an inner-city, industrial suburb, which meant that the practice was directed towards the needs of the elderly who suffered with multiple ailments and younger adults with chronic illness and disability arising from accidental injury. The centre provided the services of a full-time surgeon, nurse, physiotherapists, psychologist and social worker, radiologist and visiting consultants. Collings – the general practitioner – retained responsibility for each patient and treatment was coordinated through regular meetings between the practitioners involved in each case. The Clarke-Hiskens Medical Centre was a community health centre where ‘holistic and humane primary care’ was provided with the aim of keeping people out of hospital, and in the community, at home, and at work.107
Collings’ attempt to put into practice a form of medical service that acknowledged the contribution social factors made to illness and disability failed for lack of secure financial backing. In the prevailing climate of medical work in Australia in the first half of the 1950s, with its emphasis on curative medicine and personal services remunerated by fee-for- service, income from Collings’ patients, most of them too poor to contribute much, provided an insufficient basis for the practice. The system of hospital and medical insurance introduced by the Menzies-Page
Occasional Papers in Australian Medical History, No 9, University of Sydney, 1999, (pages unnumbered). 105 The two surveys were published as follows: J. S. Collings, ‘General Practice in England today, A Reconnaissance’, Lancet, vol 1, 1950, pp.555-585, and J. S. Collings & D. M. Clarke, ‘General Practice Today and Tomorrow’, New England Journal of Medicine, no 248, 1953, pp.141-145 and pp.183-194. 106 Obituary contributed by the psychologist, Oscar Oeser, Emeritus Professor of Psychology at the University of Melbourne, MJA, vol 1, 1971, p.1347. For Oeser, see Chapter Four. 107 Petchey, op. cit.
100 government in 1951 provided payment for pensioners through the Pensioner Medical Service but this did not extend to specialist medical services. Even insured patients would not have had cover for the services of the social worker or physiotherapist. For patients eligible for Workers’ Compensation payments, the provision for rehabilitative treatment was likely to be limited.108 The British Medical Association was prepared to make an exception in relation to provision for people suffering from tuberculosis, and accept the public provision of a range of services directed towards prevention, cure and rehabilitation, but it was not prepared to extend this support for ‘social medicine’ to the rest of the population. Roland Petchey attributes the failure of Collings’ project directly to the refusal of the Victorian branch of the association to provide support of any kind.109
There is no apparent connection between Eric Saint’s attempts to establish the discipline of social medicine at the Clinical Research Unit (which straddled the Royal Melbourne Hospital and the Walter and Eliza Hall Institute) and Collings’ attempt to implement the practical content of social medicine in Richmond. Nor is there any indication of a relationship between either of these two ventures in social medicine and the discussions that were underway in the early 1950s between John Lindell, medical superintendent at the Royal Melbourne, and the committee of management of Mount Royal Home and Hospital for the Aged, regarding the development of a geriatric service. Nevertheless, these concurrent projects suggest that social medicine did exert a broad, if subtle, influence on medical thinking, at what may be described as the geographical and intellectual centre of the Victorian medical community – the cluster of institutions around the inner-city public hospitals, research institutes and the medical school at the University. Burnet’s reference to social medicine in his history of the Hall Institute and the Clinical Research Unit,
108 After he was forced to close the practice, Collings found another avenue for developing a holistic approach to medical care. When Leigh Wedlick resigned from his position as Medical Officer for Physical Medicine at the Royal Melbourne Hospital, Collings took his place. There Collings worked to convince medical colleagues of the merits of developing the department as a rehabilitation setting under the direction of the doctor in charged of the department. He resigned due to ill health in 1970, without having succeeded, and died some time later at the age of 53. RMH Archives/Medical Superintendent’s File/ N-P/ 1958 and 1960. 109 Petchey, op. cit.
101 suggests the existence of an undercurrent of medical ideas in Melbourne in which social medicine exerted a significant influence.
Apart from his position as medical superintendent at the Royal Melbourne Hospital, there is little else to connect John Lindell with this undercurrent of opinion. However, the inclusion of features of social medicine in the medical services he established in his position as first medical Chairman of the Hospitals and Charities Commission, a position he was appointed to in 1953, suggests that he was, at least, sympathetic to the social medicine perspective.110 Lindell, himself, did not theorise about his approach to developing the State’s hospital system and he certainly showed no sign of subscribing to the critique of the reductionist model that is implicit in social medicine. His career was almost entirely administrative in its focus. Originally trained as a pharmacist, he completed medical training in 1940 and following his year of residency, was appointed deputy medical superintendent at the Royal Melbourne in 1942, and medical superintendent a year later. He qualified for Fellowship of the Australian Institute of Hospital Administration with a thesis entitled, ‘A Regional Plan for Hospital Development’ and his principal task as Chairman at the Commission was to implement a regional hospital service in Victoria.111
However, in addressing this task Lindell did support the implementation of medical services based on a socio-medical model of illness and disability, and so he may be associated with the social medicine orientation. These services were the geriatric services located in the benevolent homes, specifically for elderly patients at risk of needing custodial care, and two small rehabilitation centres for younger patients injured in motor car or accidents, or adults disabled by chronic conditions, who were not eligible
110 Annual Report Mount Royal, 1954. The report suggests that it was Lindell who initiated moves to establish a geriatric services as a cooperative venture between the Royal Melbourne and Mount Royal Hospital; see also Uhl, op. cit. p.178. Lindell’s appointment as Chairman, and that of the other two commissioners, occurred under controversial circumstances. W. P. Barry, Minister for Health in the Cain Labor government was dissatisfied with C. L. McVilly’s interpretation of his role as Chairman, and McVilly was, in the end, obliged to resign. McVilly may have been too ready to share the views of community representatives as to the need for hospitals in their localities and, consequently, involve the State government in expenditure beyond its control and capacity. The episode is described from the point of view of a community attempting to build a hospital by H. W. Nunn, A Most Ingenious Hospital, A History of Sandringham and District Memorial Hospital, 1940-1990, Sandringham and District Memorial Hospital, Sandringham, Victoria, 1990, pp.75-85. 111 Australian Dictionary of Biography, vol 14, 1940-1980, Melbourne University Press, Carlton South, Victoria, p.97-98.
102 for the services provided by the Commonwealth Rehabilitation Service.112 These services had the potential to provide the practical content of social medicine. In referring to the candidate for custodial care as ‘neglected’ within existing hospital services Lindell clearly acknowledged the defects of medical services based solely on the provision of curative services. In proposing the establishment of rehabilitation services he implicitly supported another model of hospital service and medical work, a model in which social and medical factors were combined in the contributions of a ‘team’ of health professionals under medical leadership, and one in which the objective was the restoration of social function, not merely physiological function.113 In practical terms, the proposed combination of medical, para-medical and welfare provisions in geriatric and rehabilitative services, services whose objective was similar to Collings’ medical centre, meant introducing features of social medicine into the management of the State’s hospital services.
Nevertheless, the organisation and funding of medical work that was established in the national health service introduced in the early 1950s ensured that the services Lindell promoted were unlikely to impinge on private medical practice. It was only the poor, infirm aged, who ‘blocked’ beds in the public hospitals because they had nowhere else to go, who were likely to come to the attention of a geriatric service. As in the 1920s, in Cumpston’s plans for the Commonwealth Department of Health, ‘social medicine’ was given a local interpretation in the establishment of geriatric services which did not contest the fundamental biomedical reductionism
112 The Commonwealth Rehabilitation Service was established in 1941 following the recommendation of the Joint Parliamentary Committee on Social Security. It linked the Invalid Pension with the provision of rehabilitation treatment, putting into effect one of the recommendations Cumpston had made twenty years previously, J. Tipping, Back on Their Feet, A History of the Commonwealth Rehabilitation Service, Commonwealth of Australia, 1992. 113 The influence of social medicine in Victoria became clearer in the 1960s when Thomas McKeown’s notion of a ‘balanced hospital community’ informed the development of services at the Alfred Hospital and the new Monash Medical Centre. See chapter five. McKeown, Professor of Social Medicine at Birmingham University followed Ryle as leader in the discipline of social medicine, introducing the organisation of hospital services into the social medicine perspective. The ‘balanced hospital community’ was promoted as a means of linking hospital and community and incorporating all types of afflictions within the one system of care and medical training. Lindell presided over the Victorian developments so it may be assumed that he was sympathetic to the ideas that stimulated them. In 1968, at the Third Australasian Medical Congress, Lindell spoke in the ‘Section of Preventive and Social Medicine: Community Medicine’ on the topic of ‘The Hospital and the Community’, promoting the establishment of a relationship between local hospitals and their communities by providing facilities for general practitioners to treat their patients in hospital, MJA, vol 2, Supplement, 1968, p.87.
103 that underpinned medical understanding of disease and disability. It was an interpretation which ensured that, in the context in which medical work was organised and funded in Victoria, it was ‘social medicine’ for the poor, located outside the mainstream of medical work and linked into to the administrative requirements for the efficient management of public hospital beds.
A comparison between the introduction of geriatric services in Queensland, which also occurred in the late 1950s, and Victoria highlights the isolation of such services from mainstream hospital and medical services from the very beginning. In Brisbane geriatric services were introduced as part of the redevelopment of a chronic hospital, the Diamantina Hospital, renamed the Princess Alexandra Hospital, under the direction of a government department responsible not only for funding hospital services but also providing them. The insertion of socio-medical services into acute hospital services in this instance was directly related to the integration of social medicine in the 1930s (albeit also a local interpretation), by Sir Raphael Cilento into the activities of the Department of Public Health and the Queensland medical school. Geriatric services were therefore a coherent element in the overall provision of hospital services, not, as in Victoria, a measure to ensure the efficient use of services for the infirm aged.114
Social Medicine and Old Age Infirmity in 1950s Victoria Lindell’s appointment as first medical Chairman of the Hospitals and Charities Commission and the innovations he attempted, may be interpreted as an instance of what Kewley describes as the ‘new attitudes
114 The introduction of geriatric services as part of an acute hospital took place under the direction of Abraham Fryberg (later Sir Abraham) who succeeded Cilento as Director- General of Health and Medical Services in Queensland, and who carried on the ‘social medicine’ emphasis established by Cilento, R. Patrick, A History of Health & Medicine in Queensland 1824-1960, University of Queensland Press, St Lucia, Queensland, 1987, p.111-112; P.G. Livingstone who was appointed to develop the geriatric unit at the Princess Alexandra described its activities at the Geriatrics Conference in Melbourne in 1962, Geriatrics Conference 1956-1966, Hospitals and Charities Commission, Spring St Melbourne, nd, pp.78-87; see also Lefroy, 1988, op. cit. p.60. A brief history of the Diamantina Hospital may be found in, R. Wood, ‘The Diamantina Hospital’, People, Places & Pestilence, ed M.J. Thearle, University Department of Child Health, Mater Children’s Hospital, South Brisbane Australia, 1986. The wards of this hospital must have resembled the infirmary wards of Mount Royal Home and Hospital for the Aged in Melbourne. They accommodated many long-term patients suffering from ‘rheumatoid and other arthritis, strokes, heart disease, … chronic bronchitis, kidney disease and senility’, p.49.
104 and habits of thought’ that characterised the approach of governments to the task of postwar reconstruction.115 From this point of view the provision of health and welfare services entailed an equitable distribution of services, provided by trained workers, based on a rational estimation of need. The Hospitals and Charities Commission (HCC) replaced the Charities Board in 1948, a change implemented by a Labor government in Victoria, seeking to emulate its centralising, policy driven federal counterpart. The three members of the Commission were full-time paid officials, one of whom had to be qualified in medical administration, it had its own staff and a more extensive range of responsibilities than the Board. These included advising the Minister of Health, coordinating and regulating the location and building of hospitals, developing common management practices in them and standardised levels of staffing and staff training.116
However, these apparently new habits of thought were not so pervasive that politicians in Victoria were inclined to depart from customary practices. The adoption of the structure of a semi-autonomous Commission, and not a policy-making ministerial department to administer the development of hospital services, reflected a continuation of government by the control of finances rather than the active implementation of policy. The voluntary element in the provision of hospital services in the State was preserved in the lack of authority given to the Commission to enforce any particular line of action on committees of management, despite the increasing role of the State and Federal government in funding their activities. The Commission’s coordinating task was confined to advising, and to structuring the subsidies it provided so they were put to uses the Commission agreed were necessary. The preservation of local customs such as these led The Age newspaper to
115 Kewley, op. cit. p.173ff. The work of the Joint Parliamentary Committee on Social Security is an example of this rationalised and expert driven approach, although, as Shaver notes, it was initially a ‘pragmatic device of wartime politics’, Shaver, op. cit. pp.411-431. The replacement of the Charities Board by the Hospitals and Charities Commission was recommended by the State Development Committee in Victoria, to provide a coordinating authority to ‘plan and organise an orderly and needed extension of modern hospital facilities throughout the State,’ Inall, op. cit. 116 Inall, op. cit; Victoria Year Book, 1949-50.
105 commend legislators of all parties for preserving the ‘spheres of activity and service’ within the new body. 117
Around the time he was appointed Chairman of the Commission, Lindell, visited Britain where he met Marjory Warren and Lionel Cosin, and W. F. Anderson (later Sir William), a leader in establishing geriatric medicine in Scotland.118 All three physicians were later to play a part in the development of geriatric medicine in Victoria. While there may have been a personal element to Lindell’s interest in ‘the aged’, there was also an administrative imperative. Throughout the decades from the twenties to the fifties the State government had gradually assumed greater responsibility for funding the care of those of the chronically ill and disabled in the State who lacked the resources to provide for themselves. Elderly people were always prominent amongst this group simply because, as Sidney Sax noted, chronic illness and disability is more characteristic of advancing age.119 Nonetheless it is worth asking why the focus on the elderly persisted in the ‘new postwar order’ when the attention of governments and some medical practitioners shifted towards the chronically ill and disabled. After all the benevolent home wards accommodated younger adults afflicted by incurable disease or by disabling injury from work and motor car accidents. In 1948 and again in 1950, anonymous editorials in the Medical Journal of Australia made the point that from an administrative point of view there was no need to distinguish the needs of the aged from the rest of the long term sick. Overall this group required services that were not included in the curative services provided in the acute hospitals. H. O. Lancaster posed the problem in terms of dependency, a problem that all societies faced to greater or lesser extent.120
117 B. McCoppin, ‘The Hospital System of Victoria: Administration and Policy Making’, MA Thesis, La Trobe University, 1974, Chapter 2; A.F. Davies, ‘The Government of Victoria’ in The Government of the Australian States, ed, S.R. Davies, Longmans, London, 1960, pp. 182-186. The preservation of the ‘service’ element in the provision of health and welfare services reflected a governmental approach whereby policy-making was situated within semi-autonomous entities, the role of the minister being to overseeing the distribution of funding. 118 Personal communication from Mrs Marion Shaw, March, 1997. Warren’s ideas were readily adapted by Scottish doctors and, it appears, more quickly introduced into medical teaching in Scotland, Sir William Ferguson Anderson, ‘Geriatrics’, Improving the Common Weal, Aspects of Scottish Health Services 1900-1984, ed G. McLachlan, Published by Edinburgh University Press for the Nuffield Provincial Hospitals Trust Edinburgh, 1987. 119 Sax, 1967, op. cit. 120 H. O. Lancaster, ‘Aging in the Australian Population’, MJA, vol 2, 1954, pp.548-553.
106
It needs to be clear, at this point in the early 1950s, that what is under discussion here is the establishment of a form of civilian hospital service directed towards the needs of the chronically ill and disabled who would otherwise have been admitted to institutional care. The Repatriation Department hospitals had, since the First World War, provided services directed towards returning injured service personnel back to civilian life at whatever level of independence was possible. A number of voluntary bodies had established rehabilitative services for individuals with specific disabilities and in 1948 legislation was passed to establish the Commonwealth Rehabilitation Service to provide similar services for injured and disabled civilians of working age.121
Certain elements of a rehabilitation service were in fact provided at some Melbourne Hospitals. The Repatriation General Hospital, first at Caulfield and then at Heidelberg, had always combined medical treatment and rehabilitation.122 When the Alfred Hospital took over convalescent wards at Caulfield Hospital, social workers and occupational and physiotherapists provided treatment directed towards restoring disabled patients to the community. The physiotherapy department at the Royal Melbourne Hospital and no doubt at the other public hospitals also, provided a range of treatments by therapists with the aim of restoring function, under the direction of hospital consultants.123 At the Austin hospital plans were underway for developing rehabilitation services for patients paralysed as a result of spinal injury.124 The Children’s Hospital
121 Kewley, op. cit. p.326ff summarises rehabilitative services funded by the Commonwealth for, in the beginning, applicants for the Invalid Pension and sickness and unemployment benefits and sufferers from tuberculosis. For a survey of services provided by voluntary groups in the late 1950s see, F.H. Rowe, ‘Rehabilitation in Australia’, International Labour Review, vol LXXVII, no 5, 1958, pp.463; and for a longer account of the Commonwealth Rehabilitation Services see Tipping, op. cit. 122 Ford, 1996, op. cit. and G. Hunter-Payne, Proper Care, Heidelberg Repatriation Hospital, 1940s –1990s, Allen & Unwin, 1994. 123 Annual Reports, Alfred Hospital early 1950s. The development of occupational therapy as a profession is described in B. Cameron, The Work of Our Hands, A History of the Occupational Therapy School of Victoria, Gippsland Times Commercial Printing, Sale, Victoria, nd, p.55-56; for social work see Laurence, op. cit. 124 G. G. Burniston, ‘Rehabilitation of the Disabled, with Particular reference to its Present Progress in Australia’, MJA, vol 1, 1956, p.480. Dr Burniston gained his experience in rehabilitation during war service in Britain. In 1956 he was Principal Medical Officer in the Commonwealth Department of Social Services and in 1959, elected President of the Australian Association of Physical Medicine and Rehabilitation. Howard Rusk, a prominent American medical rehabilitationist, visited the Austin Hospital in 1956 to advise on the development of rehabilitation services for spinal injuries, Gault & Lucas, op. cit. p.139. See also footnote 131 in this Chapter.
107 had established an annexe, first at Hampton and then at Frankston, to provide extensive services, including schooling, for children who spent long periods in hospital.125
Had John Lindell been so disposed, he could have approached the provision of specific hospital services for the chronically ill and disabled in terms of an overall strategy to manage dependency. In New South Wales, at the Royal Newcastle Hospital, the medical superintendent, C. M. McCaffrey and Richard Gibson, a physician at the hospital, had established what McCaffrey described as a second level of hospital services in the provision of rehabilitative treatment and domiciliary services. McCaffrey and Gibson aimed to reduce the need for custodial care by providing services to support the chronically ill and disabled in their own homes.126 Elsewhere in that state, a small group of medical practitioners were in the early stages of promoting a medical role in the provision of rehabilitative services to hospital patients, whose independence was limited by incurable conditions, immediately following treatment during the acute phase of illness. In the mid 1940s doctors interested in the field which became known as medical rehabilitation, formed the Australian Association of Physical Medicine, five years later ‘Rehabilitation’ was added to the title.127 In 1955 Naomi Wing, convenor of a committee commissioned to establish a rehabilitation centre at the Royal South Sydney Hospital, addressed the New South Wales Branch of the British Medical Association. The rehabilitationist’s field of work, she
125 For the Children’s Hospital see Yule, op. cit, Chapter 13. 126 McCaffrey, accompanied by Richard Gibson, described the service in these terms at the Geriatrics Conference in 1961, making the point that he saw no need to distinguish rehabilitation services according to the age of the patient. ‘Geriatric Care in the Newcastle Hospital’, Geriatrics Conference 1956-1966, op. cit, pp.24-26. The service, established in 1954, was only given the title ‘Geriatric Service’ some years later. Grace Parbery, the social worker who worked with Gibson from the beginning, said, some years later, ‘there was no preconceived idea that they should work in Geriatrics. It was the result of natural progress, ‘They looked at problems as they developed and developed a programme as they went along’, M. Henry, ‘Pioneering in Geriatrics: The Newcastle Experience’, in Patients & Practitioners & Techniques, Second National Conference on Medicine and Health in Australia, 1984, eds A.H. Attwood & R.W. Home, Medical History Unit & Department of History and Philosophy of Science, University of Melbourne, Parkville, Victoria, 1985, p.56. 127 L. T. Wedlick, ‘Physical Medicine and its Place in the Rehabilitation Programme’, MJA, vol 1, 1966, p.514. In the 1950s Australian doctors still had to travel to England to complete a Diploma in Physical Medicine but in the 1960s the Australian Society supervised its own Diploma program in cooperation with the Postgraduate Federation. For the role of the Federation in promoting postgraduate medical training see, A.M. McIntosh, ‘The Development of Post-Graduate Training in Medicine in Australia’, MJA, vol 1, 1951, pp28-32.
108 said, was found in the ‘increasing numbers of aged and permanently disabled persons’ who had suffered illness or injury to the extent they were unable to resume life in the community.128
Leigh Wedlick, the medical officer in charge of the physiotherapy department at the Royal Melbourne Hospital was the principal spokesman for medical rehabilitation in Melbourne.129 He had hoped initially, to develop the department as a domain of physical medicine, with the addition of rehabilitation treatment provided under special medical supervision, but his ambition was frustrated by lack of support from his colleagues. The department continued to function as provider of services that were, principally, ordered by the consultants in charge of the units where patients were admitted.130 In the early 1960s, after retiring from his position at the Royal Melbourne he established one of the two small rehabilitation hospitals that John Lindell promoted but, overall in Victoria, medical interest in this aspect of the healing process was limited. The impetus to establish a medical role in the provision of rehabilitative services came principally from the Hospitals and Charities Commission and the few doctors who were interested were, until the early 1970s, only able to find part-time and honorary positions in these two small rehabilitation hospitals.131
There was a degree of uncertainty in the early 1950s about the theoretical justification for the role of the medical rehabilitationist. C. M. McCaffrey believed that the only justification for separate rehabilitation units within a hospital was the development of new ideas, otherwise restorative therapy should be incorporated into routine hospital services. Naomi Wing concurred, citing Dr Howard Rusk, the American physician who promoted rehabilitation as a natural extension of existing hospital services under
128 M. N. Wing, ‘Medical Rehabilitation’, MJA, vol 1, 1955, pp.705-714. 129 L. T. Wedlick, 1966, op. cit. 130 L. T. Wedlick, A Doctor’s Life (Odyssey), nd, held in RMH Archives. 131 The first steps towards establishing a rehabilitation hospital were taken in the mid 1940s when the committee of management of the Melbourne Convalescent Home for Men approached C.L. McVilly, then Chairman of the Hospitals and Charities Commission, to inquire whether their property could be used for this purpose. A committee was formed to consider the proposal. McVilly wanted to interest other parties in the project, such as the Red Cross, and Colonel R. D. Galbraith had agreed to join the committee. VPRS 4523/P1/138/1341. Galbraith, a British physician who came to Australian in 1923, became medical superintendent of the Frankston Orthopaedic Section of the Children’s Hospital in 1934. During the war he supervised the fitting out and operation of hospital ships and in
109 special medical control.132 Leigh Wedlick wrote in 1966 that there was nothing new about rehabilitation, ‘it has been practised by every doctor who sees his patient over a heart attack and supervises his convalescence till he can be graded back to work’, thus transporting the general practitioner’s role into the hospital environment.133 A similar point was made by a West Australian advocate of medical rehabilitation when he said, that the medical rehabilitationist was undertaking a duty to those patients who lacked a general practitioner.134 G. G. Burniston, who transferred his experience in medical rehabilitation in Air Force hospitals, to the civilian field as Chief Medical Authority for the Commonwealth Rehabilitation Service in Melbourne, provided a somewhat self-serving justification for a medical role in rehabilitation. Therapists and nursing staff were limited in their capacity to understand the ‘medical component of disability’, and even though their knowledge of the social aspects of disability exceeded that of medical practitioners, they could not be expected to communicate as equals with consultants and general practitioners.135
In the postwar shift of medical attention to conditions previously excluded from the field of hospital work, the medical advocates of a socio-medical model of hospital service directed towards the ‘social’ goal of returning the sick and disabled to an active place in the community, were not sophisticated in justifying a claim to specialist expertise.136 However in answering the question of why John Lindell chose to introduce age-related
1945 was appointed Chief Rehabilitation Officer for the Australian Army, he then was appointed Commonwealth Coordinator of Rehabilitation, Yule, op. cit. p.218. 132 Howard Rusk was one of the few American physicians who transferred their interest in physical medicine and rehabilitation out of the armed forces hospitals, to the general community, Gritzer & Arluke, op. cit. pp.91-94. Rehabilitation medicine was associated with philanthropic institutions such as the Kabat-Kaiser Institute in California and the Bellevue Hospital in New York. It was after her experience of rehabilitative treatment that the Newcastle nurse suffering from multiple sclerosis, took the first steps that led ultimately to the establishment of rehabilitative services at the Newcastle Hospital by Drs C. McCaffrey and Richard Gibson, Henry op. cit. 133 Wedlick, op. cit. 1966, p.515. 134 C. Anderson, ‘The Scope of Rehabilitation in Australia, With a Suggestion for the Future’, MJA, vol 1, 1955, p.161. 135 G. G. Burniston, ‘Rehabilitation in Australia’, Postgraduate Medicine, vol 25, no 1, 1959, pp.49-55. 136 Unlike the British orthopaedic surgeons who wanted to align their specialist skills with the establishment of independent trauma/accident centres, ‘in the hope that (they) … might improve (their) financial future and professional position’, and who consequently were pushed to a degree of introspection they may not otherwise have attempted. ‘ “ Real rehabilitation is getting into the mind of a man, finding out what his anxiety is and his worry and fear, and removing them”’, Cooter, op. cit. p.210-211.
110 rehabilitation services rather than the general medical rehabilitation proposed by members of the Association for Physical Medicine and Rehabilitation, theoretical justification does not even enter the picture. The specialist consultants who held sway over the services provided in the public hospitals in Victoria, were simply not interested in the introduction of a medical role in providing socio-medical services to supplement acute care services. They were, it seems, satisfied to leave the provision of such services to therapists and social workers who were ultimately answerable to these specialist consultants.
Lindell’s decision, as Chairman of the HCC, to introduce age-related rehabilitation services was formed in a context where attention was directed by local circumstances towards the aged. Elderly patients were prominent amongst those patients who were seen as ‘blocking’ acute hospital beds, who could not be discharged because they had nowhere to go.137 In addition, there was a focus on the infirm aged in the community where there appears to have been a perception that accommodation for this group was inadequate. General practitioners found it difficult to find places for infirm elderly patients, ‘indigent, enfeebled old folk, some bedridden, most of them dirty and frequently verminous, some receiving charity with a grudging hand, others receiving none at all’.138 Others watched their younger women patients attempt to provide care for an infirm parent and a growing family in houses ill-suited to such diverse and often conflicting needs.139 One woman in this position wrote to the
137 Early in the 1940s the annual reports of the medical superintendent of St Vincent’s Hospital noted that the average length of stay of patients was increasing and that patients ‘appeared to be more elderly than before’, Egan, op. cit. p.178. The Annual Report for the Royal Melbourne Hospital for 1949-50 noted that one in ten of the hospital’s patients could not be discharged because of destitution and infirmity. While the number of claimants for custodial care may have increased, the supply of beds for custodial care had diminished according to Hutchinson who notes that hospital beds previously available for long-term care had been taken over for acute care. The example of the changes introduced at the Austin Hospital from the late 1920s indicates how this change may have come about. In addition, the manager of Mount Royal Home and Hospital for the Aged was quoted in The Age in the 1940s, to the effect that no infirmary beds had been added to Victoria’s stock in 60 years, VPRS 4523/P1/260/2242. Beds at the After Care Hospital may also have reverted to their original purpose, for mothers and babies, during the rise in birthrates in postwar Victoria, reducing those available for the infirm aged. 138 MJA, vol 2, 1952, p.490. 139 The problems experienced by families arose not only from the lack of accommodation for the infirm aged but possibly also from an overall shortage of housing arising from low levels of building during the Depression. Wilfred Prest questioned the degree of overcrowding in Melbourne during wartime. He concluded his survey of housing in Melbourne at this time, with the comment that while there was a degree of overcrowding, especially in poorer suburbs, ‘popular ideas of dwellings being crammed to capacity with
111 Secretary of the Charities Board, Mr. McVilly, in 1944, asking for assistance in finding a place for her 85 year-old father-in-law. His three daughters were unable to care for him, she wrote, ‘one is in a delicate state of health, one works in service and one is mental’. She herself had high blood pressure and in addition to her father-in-law, who had to have everything done for him, the household included her married daughter and husband, with a baby on the way. She made her request on ‘doctor’s orders’ because she simply had too much to do.140 Nurses in the Melbourne District Nursing Society, set up originally to provide nursing care for mothers and babies, found, by the early fifties, the focus of their work had shifted to the care of infirm old people, who often lived in very poor circumstances.141 The provision of hospital beds for the chronically sick was noted as one of the most urgent needs by Hutchinson in the recommendations made following his survey of ‘old people’ in Victoria.142
Many of the problems faced by Victorians in providing suitable care for infirm old people arose from the restrictions imposed on the provision of community facilities such as housing and hospitals while the country was at war. Their plight became more noticeable by the early fifties when higher levels of employment and new housing projects diminished signs of poverty in other sections of the Victorian population. In the late 1940s, the subsidies for housing introduced by the Chifley government promised to alleviate the problem of housing the well aged. By rights, the State government department most suited to take on the task of facilitating the distribution of this funding would have been the Housing Commission. However, the Chairman of the Hospitals and Charities Commission at the time, C. L. McVilly, gained the approval of the Minister for Health, for the HCC to undertake the role. In addition to supervising the provision of infirmary accommodation in the benevolent institutions, the Commission then had the responsibility of registering charities that wished to develop housing for the ‘well’ aged.143 The separate matters of providing suitable struggling humanity’ were exaggerated, W. Prest, ‘Housing, Income, and Saving in War- Time, A Local Survey’, Department of Economics, University of Melbourne, 1952, p.147. 140 VPRS 4523/P1/115/1120. 141 Rosenthal, op. cit. p.157. 142 Hutchinson, op. cit. p.157. 143 When the Chifley government promised subsidies for housing that could be used by communities to erect accommodation for the elderly, Mr. McVilly, proposed that the authority to supervise these subsidies should be given to the Hospitals and Charities Commission instead of the Housing Commission, a more appropriate body. Possibly he
112 accommodation for elderly Victorians, and the provision of medical and nursing care for the sick and infirm amongst them, were thus combined in the activities of the Hospitals and Charities Commission.
The emphasis on ‘the aged’ in the operation of the Commission, combined with the custom in Victoria, of the provision of hospital and welfare services by charitable bodies, although heavily subsidised by the State government, ensured that in Lindell’s view of the problems posed by demands for infirmary accommodation, age occupied a prominent place. An existing disposition in the Victorian community to focus on the aged in charitable work was, in the late 1940s and early 1950s, reinforced by the influx of literature from the United States and Britain where, in the 1940s, the topic ‘the problem of the aged’ had emerged as a focus of concern for policy makers and social scientists.144 In these societies the ageing of the population was more marked than in Australia where it was obscured by growing numbers of younger adults and children through immigration and a rising birthrate.
Shortage of infirmary accommodation was only one aspect of a run-down hospital system, impoverished during the Depression, neglected during wartime and limited in capacity by the reliance on the voluntary sector to provide services according to local perceptions of need. As the Commission confronted the situation it did so in conditions of financial stringency particular to Victoria in the early 1950s.145 In these circumstances the plans put forward by the Commission, while highlighting fresh lines of development in regionalisation and rationalisation of services and staff training, also emphasised economies through the use of existing institutions wherever possible. In his report to the Parliament for the year 1953-54, Lindell noted two priorities in the hoped these subsidies could be diverted to provide infirmary accommodation. It was in this manner that the Commission became responsible for coordinating housing for the well aged in addition to subsidising the care of the infirm. VPRS 4523/P2/947/72/1. 144 The establishment of the Old People’s Welfare Council in the early fifties, by the National Council of Women, was a direct imitation of what had been done in Britain some years earlier and the immediate objectives of the Council were also modelled on the British experience, A. Norris, Champions of the Impossible, A History of the National Council of Women, 1902-1977, The Hawthorne Press, Melbourne, 1978, pp.95-98. 145 Davies, 1960, op. cit. p. 235. When the states ceded their power to levy income tax to the Commonwealth in the early 1940s, the level of reimbursement was based on existing expenditure. Davies notes that the seven years of careful spending of the Dunstan Country Party government meant that later, Victoria had to ‘pay dearly in lowered reimbursement
113 Commission’s forthcoming activities: the provision of more general hospital beds and the provision of beds for patients excluded from those institutions – the chronically ill and the convalescent.146 The phrase ‘within the limits of funds available’ set the scene for the implementation of Lindell’s plans and ensured the existing emphasis on the special provision for the aged would continue because it promised to provide the cheapest alternative.147
Lindell announced his plans for tackling the ‘problem of the aged’ at a meeting in 1954, with representatives of Mount Royal and the Queen Elizabeth Home at Ballarat. He began with the announcement that a special Geriatrics Division had been set up within the Commission with the responsibility for supervising the organisation and provision of services for the aged. Elizabeth Johnson, a nurse, had been appointed divisional officer, and she had already begun her duties with a survey of accommodation for the elderly in the metropolitan area.148 The centre- point of these services was to be a Geriatric Unit located in each of the benevolent homes throughout the State. From here, under the direction of a medical practitioner appointed as geriatrician, patients from the general hospitals and the community, who would otherwise be candidates for custodial care, were to be classified according to their degree of dependence. The process of classification was to be linked to the provision of restorative treatment to make the most of any individual’s capacity for independence in the tasks of everyday living, followed by discharge to whatever form of accommodation best suited his or her needs.149 The objective Lindell said, was to set up a ‘chain of care’ for old
grants’ from the Commonwealth as it struggled to provide for a steadily increasing postwar population. 146 Annual Report Hospitals and Charities Commission, also VPRS 6345/64/X1091/7. 147 Notes of a meeting between John Lindell when he was medical superintendent at the Royal Melbourne Hospital, and the superintendent of Mount Royal, Colonel Robert Elliott, give the cost of a bed in the proposed geriatric unit as between ten and fifteen pounds per patient, per week. At the Royal Melbourne the bed cost was thirty pounds per week and in the existing accommodation at Mount Royal, approximately five pounds per week, 16/6/53, JHL:IC, from Personal Papers Dr John Shepherd. 148 Marion Shaw, a registered nurse, who was appointed officer in the Geriatric Division in 1972, reported that one of the Division’s aims was to assist families seeking accommodation for ‘people in need’ and that Division staff were chosen carefully for this ‘special role’, personal communication, M. Shaw, March, 1997. 149 VPRS 4523/P2/947/72/2. Annual Report Hospitals and Charities Commission 1955, 1956.
114 people throughout a specified region – a chain extending from the general hospitals, through the geriatric unit, to hostels and homes in the community, and into the homes of individuals through the provision of domiciliary services: From this central body there would be feelers extending out into every home. It should be possible to docket every old person in the region … to know their condition.150
Conclusion When the medical ‘gaze’ in Victoria finally turned to the ‘unkempt’ garden of the infirmary wards of the benevolent institutions in the 1950s, it was the ‘gaze’ of the medical administrator, not the clinician. In this respect the introduction of geriatric services, and the role of the geriatrician, differed from the hospital-based services in Britain that otherwise provided the model for geriatric services in Victoria. In Britain, physicians like Marjory Warren, Lionel Cosins and W.F. Anderson, had taken a clinical view; that is, in addressing the needs of candidates for custodial care, they focused on the medical activity of diagnosis in an acute hospital setting as a means of imposing order on the demand for custodial care. They were also concerned to make the most efficient use of hospital beds, but their concern took the form of establishing a special hospital department for the infirm aged. In Victoria the geriatric service was to consist of the provision of restorative care and the supervision of patients within a network of welfare services. It was benevolent care that was to be transformed, not acute medical services.
When John Lindell spoke of addressing the neglect of this group of patients he did not refer to neglect in the provision of acute medical services, but neglect in the sense that an assumption was made that for patients in whom the capacity for independent social life was diminished, bed-care was the best provision. From this perspective the ‘unkemptness’ of the infirmary wards in the benevolent homes lay in the indiscriminate use of long-term care. Indiscriminate in humanitarian terms so that the lives of some individuals were thoughtlessly curtailed, and indiscriminate in the use of scarce public funds. Lindell, operating within a state
150 VPRS 4523/P2/947/72/2.
115 government authority that had limited power to determine what services were provided in the acute hospitals it subsidised, and limited financial resources, was in no position to ‘see’ the disorder in long-term care in the same light as his English colleagues.
There is, however, no indication that he in fact did see the situation in terms of deficient medical care. He proposed a socio-medical model of service, not as a critique of the predominant biochemical model, but as an appendage to enable it to function more efficiently. The advocates of medical rehabilitation were no more sophisticated in theorising their role. The word ‘social’ referred to provisions made for the poor through publicly funded medical intervention, an intervention that was, as in the case of Cumpston’s plans for the Commonwealth Department of Health, based on an underlying biochemical reductionism. Intellectually and organisationally, social medicine in Victoria in the 1950s was confined to a marginal area where the proximity to welfare, salaried medical work, and the association with poverty and decrepitude, ensured its exclusion from mainstream medical work.
116 CHAPTER 3 BUREAUCRACY, PHILANTHROPY AND MEDICAL INNOVATION
Introduction The previous chapter showed that in Victoria, ‘social medicine’ was adapted to address the problems posed in the management of publicly funded hospitals by a demand for custodial care. This chapter examines how the introduction of this particularly local interpretation of social medicine opened up the possibility for doctors to develop a role defined in relation to old age infirmity. The provision of care for infirm old people in the public institutions was transformed with the introduction of the role of ‘geriatrician’. It was however, a transformation that introduced a medical dimension into the general activity of providing institutional care. The charity model of care was not displaced by a medical model of service based on specialist medical knowledge; on the contrary it was enhanced by the addition of expertise in the provision of care and the management of institutions and an extension of both state and federal government funding of long-term care. Overall, the attempt to redefine the object of charitable care as the recipient of special medical services was unsuccessful. Nonetheless this narrative of frustration and disappointed does provide insight into the processes underpinning the emergence of new medical roles. Not the least of these is that in a clash between medical and community ideas about sickness, the medical perspective will not inevitably dominate.
When Graeme Larkins, appointed as the first geriatrician in Victoria in the late 1950s, gave his first public address on the topic of ‘geriatrics’, he began by saying there was nothing new about the methods that were to be used in the new geriatric unit at Mount Royal.1 The restorative treatment provided in this novel hospital setting was new only in the sense that it was to be used for old people whose disabling conditions had previously been treated by putting the afflicted person to bed.
1 G. Larkins, ‘Modern Methods of Rehabilitation’, Geriatrics Conference, 1956, in Geriatrics Conference, 1956-1966, op. cit, pp.23-26.
116 The introduction of ‘geriatric services’ into the benevolent institutions in the late 1950s and early 1960s was a collaborative effort involving the Hospitals and Charities Commission - the State government agency responsible for overseeing the distribution of government funding for hospital services - the voluntary committees of management of the benevolent institutions, and a small number of medical practitioners who were willing to take on a role removed from the mainstream of medical practice. Unlike the English physicians who provided the model for the geriatric service, Victorian doctors did not play a leading part in developing geriatric services. Their actions were secondary to the initiatives taken by the Commission and the committees of management.
In introducing the position of ‘geriatrician’, the Hospitals and Charities Commission took a more interventionist stance in the operations of the benevolent institutions as they were transformed into Geriatric Hospitals. This can be seen in the control the Commission exerted over the reclassification of the institutions and the conditions of employment of medical practitioners as ‘geriatricians’, a title introduced by the Commission to describe the medical officers employed to develop geriatric services in the benevolent homes. At the time, ‘geriatrician’ was not in common use, even in England by the physicians who developed the model used by the Commission. However, in keeping with customary practices in Victoria, whereby government funded hospital and welfare services were provided by voluntary community based groups, the role of geriatrician was shaped as much by community expectations of what provision was suitable for infirm old people as by the medical view that underpinned geriatric services.
Geriatric Services – A Community Enterprise In November 1954, John Lindell outlined his plans for introducing special hospital and medical services for the infirm aged and the chronically ill, one of the most pressing problems he faced in developing a regional system of hospital services throughout Victoria. The first step he took was to establish a Geriatric Division within the Commission, to oversee and coordinate activities in the provision of age-related services throughout the
117 state.2 The second step was to provide funding to the benevolent institutions to assist them in establishing geriatric units where restorative treatment for old people at risk of needing custodial care would be provided. Geriatric services had a dual purpose. They combined an humanitarian provision of rehabilitative services for old people whose independence was compromised by increasing age or chronic illness, with the administrative objective of limiting future demand for publicly funded long-term care. The purpose of the geriatric units has been outlined in the previous chapter; they were to be the headquarters of a medical officer, classified according to qualifications and experience, as specialist geriatrician or geriatric medical officer.3
The decision to establish geriatric services in the large benevolent homes - Mount Royal, at Parkville, Queen Elizabeth at Ballarat, Bendigo Benevolent Home, the Ovens and Murray Home at Beechworth, and Cheltenham Old People’s Home – was supported by the voluntary committees of management that ran the institutions. It was accompanied by funding, badly needed for some years, to improve the facilities of the institutions, and the addition of special medical services promised to enlarge their already extensive work in providing care for the aged and infirm. The role of the geriatrician was established in conditions where the two principal sponsors – the Hospitals and Charities Commission and the committees of management of the benevolent institutions – were united in the aim of improving provisions for the infirm aged. The union of state bureaucracy and community-based groups in this enterprise was in keeping with the customary approach to the provision of hospital services in Victoria. However, such unanimity and apparent clarity of purpose disguised the complexity of the territory that these founding geriatricians had to negotiate in order to establish a medical model of service in place of the existing charity model of care. Their activities were enmeshed in the ambiguities surrounding the operations of the Hospitals and Charities Commission and entrenched community ideas about what constituted
2 Annual Report Hospitals and Charities Commission, 1953-54, VPRS 4523/P2/72/1/947. The Commission, as a consequence of the ‘empire’ building of C. L. McVilly, who Lindell replaced as Chairman, also had administrative responsibility for overseeing the provision of services for the ‘well’ aged, see Chapter Two. 3 These proposals were outlined in the Annual Report of the Hospitals and Charities Commission for 1956. The details of this classification of hospital medical officer are
118 appropriate provision for the infirm aged. Mainstream medicine was one area quite free from ambiguity. Lack of interest in the project in this quarter was clear from the beginning.
A preliminary survey of the complexities of the bureaucratic and philanthropic environment that confronted the first ‘geriatricians’ in Victoria will assist in clarifying the factors that finally shaped the role, beginning with the establishment of the Geriatrics Division. The Division was intended to oversee and coordinate all activities throughout the state in the provision of services for the aged.4 In view of the central role the geriatric service was to play in these services, and that it was to be primarily a medical setting, it is curious that a nurse, Elizabeth Johnson, was put in charge of the Division.5 Given the position of nurses in the medical hierarchy it is difficult to understand how a nurse could provide the administrative support for a medical service. In fact, her first task, surveying the accommodation for the aged that was available around Melbourne, suggests that Lindell did not envisage the Division playing a direct role in relation to the work of geriatricians.
The other states also began to introduce a special medical role in relation to the management of old age infirmity at this time. Victoria is notable in these ventures, however, for the lack of any clearly demarcated medical responsibility in the administrative structure overseeing the field in which the ‘geriatrician’ was situated. First in Queensland, then New South Wales and Western Australia and later, South Australia, the position of Director of Geriatrics was created within the relevant government department, and a medical practitioner appointed.6 It may have been outlined in the Hospitals and Charities Commission Circular No 22/1961, VPRS 4523/P2/961/183-1. 4 Annual Report Hospitals and Charities Commission, 1953-54. 5 Johnson was the first of a sequence of nurses appointed as officers in the Geriatrics Division, VPRS 4523/P2/947/71/2. She completed general nursing training at the Children’s Hospital, then additional certificates in midwifery and infant welfare, joining the Hospitals and Charities Commission in 1951, Your Hospitals, vol 1, no 4. Her successors over the period covered in this thesis, up to the late seventies, all registered nurses, were, Doris Watkins, Rae Tabbner, and Marion Shaw. The early emphasis on accommodation is confirmed in the report Doris Watkins made of an overseas study tour in 1969. Her principal recommendation was the provision of hostel accommodation for the frail aged, distinguishing the needs of this group from those who needed long-term medical and nursing care. There was no mention however, of a medical role in making this distinction, an omission that highlights the separation between the Geriatrics Division and the doctors who were establishing the role of geriatrician. 6 Queensland took this step in the late 1950s when P. G. Livingstone, the physician appointed to establish a geriatric service at the Princess Alexandra Hospital, was also
119 Victoria’s straitened financial circumstances during the 1950s and 1960s that accounted for the failure to appoint a medical practitioner in charge of the Geriatrics Division.7 Certainly Lindell referred to the limits thus imposed on his activities in his first report as Chairman of the Commission in the comment that use would be made of existing facilities rather than the erection of new buildings.8 It was cheaper to pay a nurse as Officer in the Geriatrics Division because nurses’ salaries in these bureaucratic positions continued to be paid under the trained nurses’ award.9
Even in relation to the institutions the Geriatric Division was to oversee, Johnson had limited power. This was made clear soon after her appointment in an interview with a medical officer employed at Larundel Mental Hospital. He, hopeful perhaps that the establishment of the Geriatrics Division augured a new era in the care of infirm old people, had approached Johnson informally to enlist her aid in transferring those elderly patients who did not need the services provided in a mental hospital, to a benevolent home. The transfer of patients in this category was a constant preoccupation of mental health authority doctors since, at least, the 1920s.10 Her reply that she had no power to compel the homes to admit any particular patient, and that she was unable to assist him, left no doubt that little had changed in the ‘new’ order. It also conveys the impression that the role of nurse as the follower of medical orders in the hospital, had been transferred to this bureaucratic setting in the
appointed Director of Geriatrics within the Department of Health and Home Affairs, Geriatrics Conference 1962, p.78-87, Geriatrics Conference 1956-1966, op. cit. In New South Wales, following the recommendations of a committee set up to inquire into the provision of hospital and welfare services for the infirm aged, a Director of Geriatrics was appointed in the early 1960s. John Lindell was a member of the committee that made this recommendation. The development of rehabilitation services took place in hospitals under the control of the state government, Geriatrics Conference, 1962, Geriatrics Conference 1956-1966, op. cit.; ‘Care of the Aged and Chronically Ill’, MJA, vol 2, 1960, p.587-588. Also, in the early to mid-sixties, R. B. Lefroy, a physician at the Royal Perth Hospital gave up his position to take on the appointment of Director of Geriatrics and the commission to develop a geriatric service at the Sir Charles Gairdner Hospital, Geriatrics Conference 1964, Geriatrics Conference 1956-1966, op. cit, pp.65-70. A reference in The Age 13/6/50 suggests a committee similar to that established in New South Wales may have also been set up in Victoria. This brief note refers to a committee appointed by the state government two years previously to investigate the problem of accommodating infirm old people, and asks what has happened to this committee and its investigations. 7 A.F. Davies, 1960, op. cit. p.235. 8 Annual Report Hospitals and Charities Commission 1953-54. 9 McCoppin, 1974, op. cit. pp.50-52. 10 See Chapter Two.
120 relationship between the officer in the Division of Geriatrics and the Chairman of the Commission, Dr John Lindell.11
Possibly it was considered that Lindell would provide the medical leadership required to establish this new medical role. If so this would have been in keeping with the conditions in which the Commission operated. The work of the Commission was, fundamentally, to distribute public funding for hospital services. It had no power to compel any of the committees of management of the institutions it oversaw to take any particular course of action, relying on advising, negotiation and the structure of its subsidies to achieve any particular policy objective.12 The establishment of geriatric services was then a collaborative venture in which the funding body, the Commission, the public, in the form of committees of management, and medical practitioners, the ‘experts’, cooperated to provide a ‘community’ service.13 The Commission prescribed conditions that had to be met as the benevolent institutions developed restorative facilities, and they were subject to a process of standardisation. Nonetheless the context in which such rationalisation took place was also one in which the personal relationship between John Lindell and medical practitioners on one hand, and committees of management on the other, was an integral factor. The former individually found Lindell most supportive, and the latter were likely to find that ‘a lunch with Lindell’ would reliably result in his agreeing to whatever project the committee was promoting.14
11 VPRS 4523/P1/422/3429. 12 The implementation of public policy through semi-autonomous entities such as the Hospitals and Charities Commission was characteristic of the administration of the state of Victoria, A.F. Davies, 1960, op. cit. pp. 190-196. 13 It is worth noting that the idea behind the implementation of policy by semi-autonomous bodies such as the Hospitals and Charities Commission was initially intended to remove the possibility of political influence on the provision of public services, Davies, 1960, op. cit. pp.190-192. It was also a system whereby the Victorian community was able to participate in decisions about the establishment of services through fund raising and membership of committees of management. In the late 1970s when community participation was a clear objective of policy, this approach to the development of community services was criticised on the grounds that certain interest groups prevailed in decisions about what kind of service was necessary and in management committees, excluding others, J. Goode, ‘The Health Policy Process in Victoria’, Community Health Studies, vol v, no 3, 1981, pp.206-215. 14 Personal communication from Drs John Shepherd 23/2/98 and M. Scott 18/12/97. Interview with Dr David Quinn, a medical member of the committee of management in the early 1970s, of the Kingston Centre (formerly Cheltenham Old People’s Home and Melbourne Benevolent Asylum), Transcript Oral History of Kingston Centre, Ref 19/92. When Lindell died in 1973, obituary writers noted his capacity to combine a personal relationship such as has been noted in this paragraph, with the utmost integrity in his actions, MJA, vol 2, 1973, p.984-985
121
This very personal approach to the implementation of policy regarding hospital services had the potential for success, even in an environment where service provision was as fragmented as it was in Victoria. The potential was greater in areas where personal contact could be readily established and maintained, and this was not always the case, particularly outside the metropolitan area. However success also depended on unanimity in objective for any particular service, and in the case of geriatric services, there were fundamental differences between the committees of management in their approach to this project and the medical practitioners who depended on their support. The personal relationship between Lindell and the committees of management on one hand and the doctors who strove to establish medical services on the other, combined with Lindell’s apparent even-handedness, created an ambiguous atmosphere. This showed most clearly in relation to admission policy in the institutions. The committees of management were reluctant to give up any authority on this matter to their medical staff, and all the institutions continued to maintain the policy of admission according to position on a waiting list until the early 1970s.15 The doctors who attempted to establish a geriatric service in which admission was entirely according to a medical assessment of need, were effectively hamstrung by the continuation of waiting-list based admission. It is not clear whether Lindell ‘advised’ on this matter, but committees of management certainly did not take such advice if it was given.
Ambiguity also characterised the position of the geriatrician in relation to existing medical roles in the major teaching hospitals, a situation that arose out of the autonomy enjoyed by the committees of management of these institutions. This would not have mattered had the medical staff in these hospitals taken an interest in the project of establishing geriatric services because they did exert influence over lay members of committees. The appointment of the first doctor to develop a geriatric unit at Mount Royal Home and Hospital for the Aged appears to have set the pattern.
15 Committees of management supported their opposition to giving doctors more authority by citing institutional by-laws that prohibited any employee of the institution being given a position on the committee of management. .
122 Despite the innovatory nature of the role envisaged for the geriatrician – a role situated at the intersection of acute hospital, long-term care and community based welfare services – practitioners like Larkins were slotted into a space already occupied by the convalescent medical officer in outlying institutions attached to the public hospitals.
The role of convalescent medical officer was established in the 1920s when the first wards at Caulfield Hospital were taken over from the Repatriation Department by the State government. As Caulfield was established as a convalescent hospital, first under the control of the Royal Melbourne Hospital, and then in the late 1940s, transferred to the Alfred Hospital, patients treated there remained the responsibility of the consultants in charge of the units where they were originally admitted. The medical officers employed on the convalescent wards had responsibility only for the day-to-day treatment of convalescent patients.16 Like the convalescent medical officer, the geriatrician had responsibility for the day-to-day medical care of patients admitted to the geriatric setting, while overall responsibility for that patient’s management remained with the consultant in charge of the unit in the originating hospital where the patient was treated during the acute period of illness. The geriatrician was thus lodged in a confined and, given the existing pattern of medical work, inconsequential space, bounded by that of the consultant specialist in the acute hospital on one side, and by the general practitioner in the community on the other. John Lindell’s insistence that the role be a salaried position also set the geriatrician apart from the honorary consultants in the teaching hospitals who occupied a position at the top of the medical hierarchy, and from the fee-for-service, entrepreneurial medical practice that prevailed in other areas of medical work. Salaried medical work implied a close association between the medical profession and the state and in the views of the majority of the medical profession, something inimical to good practice.17
16 By the 1950s the Infectious Disease Hospital at Fairfield provided wards for convalescent patients, as did the After Care Hospital in Collingwood. The geriatric unit at Mount Royal was expected to have the same relationship with the Royal Melbourne Hospital as the convalescent wards at Fairfield Hospital. RMH Archives/Committee of Management Reports/vol 25; see footnote 50, chapter two. 17 RMH Archives/Committee of Management Minutes/vol 26; see Chapter One.
123 The ambiguities that surrounded the introduction of the medical role of geriatrician arose from the traditional approach in Victoria to the introduction of hospital and welfare services. That is, the state government was prepared to fund the development of services, but left it to voluntary groups to provide them and, largely, to determine the form they took and the needs they addressed.18 Other medical practitioners had succeeded establishing the practice of medicine and surgery in the voluntary institutions that developed as public hospitals by the 1930s, wresting the requisite authority from their committees of management through a process of negotiation.19 It appears geriatricians were expected to do likewise.
However, nascent geriatricians, even in their relationship with their committees of management, were in a more complex situation than were their colleagues in the voluntary hospitals. There, a basis for common interest existed between doctors and committee of management; first in the desire to maintain a turnover of patients, and second in that, from the 1930s onwards, the benefits of medical advances were clear to both parties. Although they often differed over the grounds for admission, a medical assessment of need replaced the charitable assessment not long after the institutions were established.20 The successful establishment of the geriatrician’s role on the other hand depended on a complete shift in the culture of the institutions, away from the provision of institutional accommodation to the provision of services focused on keeping infirm old people out of institutions. It was the geriatrician’s task to generate a turnover of patients, but this threatened to undermine the need for a large institution with hundreds of beds – the clearest possible evidence of a community’s care for its infirm aged and the sign of a successful committee of management. The proper operation of a geriatric service
18 In 1961 the Department of Social Studies at the University of Melbourne published a study of the effectivness of the system of voluntary welfare provision in the State, questioning whether the many public appeals on behalf of voluntary agencies were necessary in light of the provision made by the State government for capital and maintenance funding. The study concluded that while the voluntary effort was a valuable expression of community concern, existing arrangements, particularly in reference to health services meant that some areas of need were neglected and others over-supported, R. Otto & L. J. Tierney, ‘Financing of Voluntary Welfare Agencies in Victoria, Social Studies Department, University of Melbourne, 1961. 19 B. McCoppin, ‘The Government and Hospital Committees of Management in Victoria’, Australian Journal of Public Administration, vol XLII, no 3, 1983, pp.376-379. 20 Walker, op. cit. pp.45-52, pp.128-113, p.138; see also McCoppin, 1974, op. cit. p.147ff.
124 meant limiting institution-based activities to the provision of short-term accommodation to which patients could be admitted for treatment and discharged, and some long-term accommodation for individuals whose needs could not be met in the community.
There is no indication that as committees of management took up the task of introducing the facilities for restorative treatment, they seriously considered abandoning a culture of, in most cases, a century-long tradition of providing institutional accommodation for both the infirm and well aged. Any reluctance to diminish the importance of the institutions was reinforced by the difficulties that did exist in finding long-term care for people without resources who were not candidates for rehabilitation in the early period, when restorative treatment was being introduced. It was in these circumstances that the committee of management at Mount Royal decided, in 1961, to continue to provide long-term care.21 The problem faced by doctors in establishing geriatric services was that they were located in institutions that had an interest in institutional care for both the chronically ill and the ‘well’ aged. This interest was encouraged by the inclusion of funding to improve accommodation facilities alongside the introduction of a medical service, a step taken for reasons of economy, to make the most of existing institutions, and because of the overall lack of interest on the part of public hospital doctors, in the needs of the infirm aged.
Each committee of management went about the process of introducing restorative facilities according to its own ideas of what was fitting, within the limits set by subsidies provided by the Commission. In 1955, When the Hospitals and Charities Commission took over hospital accommodation that was no longer needed by the Department of Health for tuberculosis patients, it was provided with an opportunity to develop geriatric services without the impediment of an existing tradition in providing institutional care.22 The Commission and the newly formed committee of management did not, however, take this view.
21 Annual Report Mount Royal 1961. 22 Annual Report Hospitals and Charities Commission, 1955.
125 The admission of ambulant and infirm old people began while preliminary discussions were underway with Prince Henry’s Hospital regarding the involvement of that institution in establishing the geriatric unit, and well before the appointment of a geriatrician and the appropriate facilities for restorative treatment.23 No doubt it was the general pressure on the Commission to provide accommodation immediately for old people whose needs were urgent that led to this situation. Even so, the decision sits oddly with John Lindell’s hope that Greenvale would become, ‘the most modern institution in Australia for old people … and … pattern for future establishments.’24 When a doctor was finally appointed to the position of geriatrician, he was faced with an environment that had already taken on the character of ‘old folks home’, despite the aspirations of the committee and the Commission that the institution would develop as a showpiece of the new era.
At Mount Royal the construction of the geriatric unit was a joint enterprise between the benevolent home and the Royal Melbourne Hospital. It was one of only two geriatric units that were successful in establishing formal links with an acute hospital.25 This 76-bed unit was the first purpose-built accommodation for the infirm aged in Victoria, and the planning process was overseen by a consultative committee consisting of representatives of both institutions, including doctors. The committee continued in existence into the early 1970s.26
23 The proposed alliance between Greenvale and Prince Henry’s did not come about. There is no reference to any representative of Prince Henry’s at the early meetings of the committee of management, a point that suggests there was no interest on the part of that institution. Greenvale Village, Board of Management Meeting Minutes. 24 Board of Management Meeting, Greenvale Village, 22/8/55. 25 As noted in Chapter Two, plans for this unit were first initiated when John Lindell was medical superintendent of the Royal Melbourne Hospital. Notes of a discussion between Lindell and Colonel R.L. Elliott, superintendent of Mount Royal on 16/6/1953, suggest that the unit was to consist of three divisions, the first of which would accommodate patients requiring ‘active’ medical or surgical treatment’. These beds were designated ‘acute’, but it seems, not ‘acute’ in the sense that other beds in the Royal Melbourne were acute. They were to cost less, that is between ten and fifteen pounds per week, whereas in RMH, bed cost was approximately thirty pounds per patient per week, Dr John Shepherd’s Private Papers. The committee of management at Mount Royal were willing partners, following recommendations made by their manager, Colonel Robert Elliott when he returned from an overseas tour, Uhl, op. cit. p.178. The Geriatric Unit at Mount Royal and the Marjory Warren Geriatric Unit at the Princess Alexandra Hospital in Brisbane vie for the honour of being the first purpose-built hospital settings for the infirm aged, see chapter two. 26 The existence of this committee cannot be taken to indicate great interest on the part of Royal Melbourne doctors. It was most probably, principally an interest in organising a process for the speedy ‘disposal’ of infirm elderly patients. The attitude of Royal Melbourne medical staff in general, may be deduced from a letter written early in the 1950s, when the venture with Mount Royal was under discussion, by the medical staff to
126
At the Alfred Hospital the manager, at the direction of the committee of management, sought advice from Elizabeth Johnson about developing a geriatric unit in the infirmary section of Caulfield Hospital. The unit was to consist of 280 beds, incorporating the infirmary wards already in the hospital with the addition of a ward for short-term treatment. A doctor was appointed in charge of the unit along with additional nursing staff, a social worker and occupational and physiotherapists.27 The Caulfield unit differed from the others in being situated in an existing hospital complex, the Alfred Hospital having taken over all the wards of Caulfield Convalescent Hospital in the late 1940s. The medical practitioner in charge of the geriatric unit, Cecil Ashley, may not have figured high in the medical hierarchy but, unlike his colleagues in the benevolent institutions, he did work in an environment where medical authority was taken for granted.
There was no such close relationship between the other aged-care settings and acute hospitals. At Greenvale Village, early hopes that an association would be formed with Prince Henry’s hospital were not fulfilled. In 1956 the newly constituted committee of management was preparing to interview six applicants for the position of geriatrician. One of these, a physician at Prince Henry’s was offered the position of geriatrician but he refused it and the committee prepared to start the process over again.28 At
the manager of the Royal Melbourne, asking that a long-term care unit be set up by the Melbourne for its own patients. The virtue of such a unit would be that it was not under the control of the Hospitals and Charities Commission. RMH Archives/Manager’s Correspondence/Medical Matters 1/vol 15; Uhl, op. cit. p152, p.180. The Geriatric Unit was named after Sir Herbert Olney, President of the committee of management, “‘that staunch worker for the sick aged and better known as a philanthropist than as a businessman’”, Uhl, ibid. p.180. Sir Herbert was also Chairman of the Charities Board before it was replaced by the Hospitals and Charities Commission, and Member of the Legislative Council, the Victorian Upper House, p164. Initially the Royal Melbourne was represented on the consultative committee by Sir Victor Hurley, Dr Konrad Hillen and Dr J. Lindell until his appointment as Chairman of the Hospitals and Charities Commission. Mount Royal was represented by Colonel Robert Elliott, Superintendent, and Dr Alan McCutcheon, Medical Officer. In August 1960, the members of this committee were Drs. McCutcheon, Butterworth and Shepherd and Mr M.E Atkinson (Manager), from Mount Royal, and Drs Sinclair and O’Donnell from RMH. RMH Archives/Committee of Management Reports/ vol 25, and Medical Matters/ No 2/26; J. Uhl, op. cit. p.178, 27 Annual Report Alfred Hospital, 1956-57. At this time also the word convalescent was dropped from the title of Caulfield Hospital, VPRS 4523 P2/822/9-3; VPRS 4523 P2/822/9-3. 28 Greenvale Village Minutes Board of Management Meeting, 22/8/55, 16/3/56. The committee of management for this institution included two medical members, Dr Alan McCutcheon, the medical officer at Mount Royal from around 1930 to the early 1960s, and Sir William Upjohn, described by the most recent historian of the Royal Melbourne, as one
127 the Cheltenham Old People’s Home twenty beds had been set aside for short–term rehabilitative treatment prior to the erection of a purpose-built section that was opened in the early 1960s. There was already some connection between this home and Prince Henry’s Hospital, as it provided accommodation for diabetic patients from the hospital and for infirm old people who could not be discharged. The relationship between Prince Henry’s and Cheltenham continued as rehabilitative treatment was introduced, but it was not managed through a consultative committee, as was the relationship between Mount Royal and the Royal Melbourne.29 In the late 1950s and early 1960s new buildings were being erected at the two largest country institutions, the Queen Elizabeth Home at Ballarat and the Benevolent Home at Bendigo. In addition, at Ballarat a home help service was introduced to assist old people remain at home who may otherwise have applied for admission.30 At both institutions medical practitioners were appointed to the position of medical superintendent, replacing local practitioners brought into to provide medical attention on a sessional basis.
Medical Practitioners It is not accidental that the only mention so far, of the medical practitioners who took on the task of establishing the role of ‘geriatrician’, has been in passing. Unlike the introduction of other medical services - such as those provided in the public hospitals - the practitioners who undertook the task of establishing geriatric services came into the picture only after the Commission and the committees of management had set the project of developing geriatric services in motion.31 The extent to which,
of a remarkable group of physicians and surgeons who made their careers at the hospital. Sir William’s relationship with the Royal Melbourne spanned 60 years, including membership of the committee of management, A. Gregory, The Ever Open Door, Hyland House, South Melbourne, Victoria, 1998, p.164. It can only be a matter for speculation but possibly these two practitioners brought a conservative approach to their task that made it unlikely that decisive and assertive action would be taken to emphasise the medical role of geriatrician in providing services over the institutional focus already in existence by the time a geriatrician was appointed. As will become clear later in this chapter, their presence certainly does not appear to have fostered the role of geriatrician. 29 Annual Report Cheltenham Old People’s Home, 1959, 1961, 1963. 30 I.M. Dicker, ‘Home-Help Service’, Geriatrics Conference, 1958, p25-28, Geriatrics Conference, 1956-1966, op. cit; C. Robjohn, My Several Lives, H. C. Robjohns, Marrayatville, South Australia, 1988, p.88-95; Cusack op. cit. pp.195-7. 31 In introducing the role of geriatrician into the benevolent institutions, the Hospitals and Charities Commission intervened to an extent not previously known in the employment of medical staff by committees of management. The Commission determined the classification of the role of geriatrician, including terms and conditions of employment. Previously these had been a matter for private negotiation between medical practitioner and committee of management. Following the report of the committee led by J. V. Dillon in
128 in accepting positions as geriatricians, doctors were removing themselves from the mainstream of medical work is illustrated by the travelling scholarships that were awarded to three of the first geriatricians. The scholarships were funded by three philanthropic businessmen associated with Mount Royal and, as the Annual Report of the Hospitals and Charities Commission for 1954 noted, they were intended to encourage doctors to take on work far removed from other types of medical practice. In due course the scholarships were awarded to Robert Butterworth at Mount Royal, Cecil Ashley at Caulfield and David Wallace at Greenvale. Each practitioner then spent a period of time travelling to the United States, Europe and England to inspect provisions in these places for the elderly, before taking up their position.32
The doctors who took on the task of developing an active medical role in the care of infirm old people were a diverse group. The few young men who were appointed were no doubt keen to integrate the role of geriatrician into the general pattern of medical work in the state. Although there were no women amongst the first appointments to the position of geriatrician, the increased number of medical positions that accompanied the introduction of geriatric services provided hospital positions that may have been more difficult to obtain in mainstream medical work for women. They were soon prominent in the staffs of the geriatric hospitals.33 Other doctors, many of them older men towards the end of their careers, would take on the role of geriatrician for a variety of reasons, none of which was necessarily concerned with establishing a specialist field of medical work in relation to the aged.
1959, uniform conditions were introduced for all salaried medical officers in the State’s hospitals. 32 Annual Report, Hospitals and Charities Commission, 1955. One of the donors was Sir Edward Hallstrom, a businessman born in New South Wales and benefactor of Mount Royal, Uhl, op. cit. p.230; another was Sir Herbert Olney, see above; the third donor was Mr. James Ross, another member of the committee of management at Mount Royal, Uhl, p.181. 33 Mount Royal in particular seems to have been attractive to women doctors as the preponderance of female names listed amongst the medical practitioners in annual reports suggests. For some, part-time positions may have been easier to fit in with family responsibilities; for others the new role of geriatric medical officer may have offered an opening into medical work that was not available in the public hospitals. However positions in the institutions that were reclassified as Geriatric Hospitals were not the most prestigious. In this respect the expansion of possibilities for women doctors was limited at this time, being more a case of answering a demand for ‘pairs of hands’ in lower status medical work, rather than career opportunities, as was the case in Britain in the 1960s, M.A. Elston, ‘Women in the Medical Profession: Whose Problem?’, in Health and the
129
Graeme Larkins, a newly qualified physician, had returned to Melbourne shortly before John Lindell made his announcement in 1954 that geriatric services would be developed in the benevolent homes.34 Larkins appears to have had a special interest in the medical care of old people because on his way to England to complete his physician training, he stopped in San Francisco where he visited the Institute of Gerontology and Endocrinology, and the Maimonedes Hospital for the Aged. Larkins’ postgraduate training was undertaken in hospitals specifically for elderly patients, including Marjory Warren’s base at the West Middlesex Hospital.35 He was the only applicant when the position of geriatrician at the geriatric unit at Mount Royal was advertised.
Larkins was appointed to the position after the Medical Advisory Committee at the Royal Melbourne Hospital had agreed he was suitable, and given the title Geriatric Research Officer and Clinical Assistant at the Royal Melbourne – a title that suggests that in relation to the medical staff of the acute hospital, his position was considered similar to that of a general practitioner permitted to undertake limited duties in the acute hospital.36 The first task that Larkins faced in his new appointment, was to join the consultative committee overseeing preparation of plans for the unit. The committee, as noted above, was made up of representatives of the committees of management of both institutions and their respective medical staffs. As Geriatric Research Officer his position was a full-time salaried one, and he was responsible for the admission and discharge of patients to the unit and for the supervision of their restorative treatment. Also, he was allocated an Outpatient Clinic in the acute hospital in which
Division of Labour, eds M. Stacey, M. Reid, C. Heath & R. Dingwell, Croom Helm, London, 1977, pp.123-125. 34 Larkins had gone to England for higher qualifications, as many Australian doctors did at the time. He graduated during the war and spent the years immediately following graduation (and one year as RMO at the Alfred Hospital) in general practice in an isolated area of northeastern Victoria, details from Dr Larkins’ curriculum vitae submitted when he applied for the position at Mount Royal Hospital, RMH Archives/Chairman’s Correspondence no 1/Medical Matters/vol 15. 35 Ibid. 36 In England around 1950, the title Clinical Assistant was applied to general practitioners who were allocated a part time position in the acute hospitals, Stevens, 1966, op. cit. p.104. Larkins also had a part time position at the Alfred Hospital and what he described in his CV as private geriatric practice.
130 to see prospective patients.37 Then in mid-1956, just as the geriatric unit was almost ready to take the first patients, Larkins resigned from his position. The reasons for this decision can only be a matter for speculation. It is likely they were related to the restrictions imposed on developing a career as a consultant physician by the exclusion of acute care from the work of the geriatrician, and by his full-time employment at Mount Royal, separated as it was from the mainstream of medical work.38 In retrospect it seems clear that this would be the case from the outset, but it is possible that when he was appointed he believed that there was some room for flexibility.
Robert Butterworth, an English doctor with an MD qualification in physiology, was appointed geriatrician when Larkins resigned. Coming from the National Health Service in Britain, he may have been more inclined to be satisfied with the salaried role he was offered in the unit where he remained until his untimely death in the early 1970s.39 For S. J. H. Shepherd, a general practitioner employed as medical officer at the Repatriation General Hospital at Heidelberg, the new era beginning at Mount Royal offered the opportunity for an hospital based career for general practitioners that was rapidly disappearing in other hospitals in the early 1960s.40 This opportunity arose when Larkins, who had maintained
37 RMH Archives/Minutes Committee of Management Meetings/vol 26. 38 During the preliminary discussions in relation to the unit, between Mount Royal and the Royal Melbourne it appears that a more active medical role may have been envisaged. The unit was to consist of three divisions, the first consisting of wards to accommodate ‘patients requiring active medical or surgical treatment’. The unit that was built contained 70 odd beds and patients were admitted following treatment during the acute stage of their illness in the wards of RMH, Notes of Conference between Col. R. L. Elliott and Dr J. H. Lindell, 16/6/53, Personal papers Dr John Shepherd. At this stage it was also planned that the position of geriatrician would be honorary. The fact that it was salaried may be attributed to either the failure to attract interest from doctors wishing to act in an honorary position, or to the desire of the HCC to ensure stability of medical attendance in a unit associated with the care of infirm old people, an association not highly regarded in medical circles. As noted in chapter one, the early 1950s marked the final stages in the movement to establish fee-for-service as the principal form of medical remuneration in Australia. In the process the position of salaried medical officer was endowed with an opprobrium that ensured its position at the bottom of the medical hierarchy, Gillespie, 1991 op. cit. chapter 11. 39 Butterworth had applied for the position of geriatrician at Greenvale when it was first advertised but was passed over in favour of a physician from Prince Henry’s Hospital who subsequently declined the position. Butterworth was a relatively young man when he died in the early 1970s Uhl, op. cit. p.182. 40 The position at Mount Royal was unusual in that the position of specialist geriatrician existed side by side with that of medical superintendent. Dr Shepherd came to Mount Royal from the Repatriation General Hospital at Heidelberg at a time of change. Previously staffed by full time general practitioner medical officers, with visiting consultants providing specialist services, moves were underway in the hospital, to institute medical staffing similar to that in the teaching hospitals where the everyday medical work
131 his connection with Mount Royal in a part-time position as Rehabilitation Officer in the general wards of the institution, died suddenly. Shepherd, who was familiar with the possibilities of rehabilitative treatment from his work at the Repat, was appointed Rehabilitation Officer.41 Shortly after, when Dr Alan McCutcheon, the most senior medical officer at Mount Royal, resigned, he secured a new position in the institution as Medical Superintendent.42 McCutcheon had spoken about the change in medical role at Mount Royal a year or two before he retired after thirty years service, noting ‘our role is steadily switching over from custodial care to nursing and treatment care’. In his ‘conservative’ view, the introduction of restorative treatment was most notable for the mental changes it brought, the broadening of patients’ horizons from four walls and the three meals each day.43
Like Graeme Larkins, David Wallace had also recently returned from postgraduate study in England when he was appointed geriatrician at Greenvale Village in 1957. In his case it had been undertaken at the Postgraduate School at Hammersmith Hospital.44 He was a graduate of
was undertaken by trainee specialists. Shepherd had hoped for a career in general practice, preferably in the country, but illness put this out of the question. From his point of view the position at Mount Royal offered possibilities that were being eliminated from RGHH. Shortly after his appointment as medical superintendent, he was awarded a scholarship by the HCC and began the course in medical administration offered at the University of New South Wales. Personal communication from Dr SJH Shepherd 23/2/98; also see Hunter- Payne, 1994, op. cit. p.81ff. 41 Malcolm Scott, who was appointed geriatrician at Greenvale Village in the 1960s, also came from the Repatriation General Hospital at Heidelberg where he too was familiar with the provision of rehabilitative treatment, Personal communication 18/12/1997. 42 In 1959, the committee chaired by J. V. Dillon, commissioned to report on the terms and conditions of medical appointments in the state’s hospitals, noted the emergence of the position of medical superintendent as a medical career associated with specific skills and training. The Hospitals and Charities Commission responded by providing scholarships to enable doctors to gain the qualification at the only institution that provided it at the time, the University of New South Wales. This institution had been founded in 1950 and named the New South Wales University of Technology, with the intention of providing the link between university level training and industry and commerce, seen to be a necessary basis for Australia’s developing role as an industrial nation. The medical administration course was one of a number of specialised graduate courses. The institution was renamed in 1958, possibly as part of an attempt to restore its image, having been subjected to criticism in relation to its performance as a university. This criticism was part of a broader discussion characteristic of postwar Australia in which the role of the universities was examined in relation to the demands of national development, N. Brown, Governing Prosperity, Social Change and Social Analysis in Australia in the 1950s, Cambridge University Press, 1995, pp.222-227. 43 A. B. McCutcheon, ‘Retrospect’, MJA, vol 1, 1958, p.274. 44 A fitting background for a doctor to develop an interest in sickness in old age, Hammersmith Hospital had itself evolved from a workhouse infirmary, Stevens, 1966, op. cit. p.107.
132 the medical school at the University of Sydney and in contrast to most of his colleagues, was an outsider in the parochial Melbourne medical world. However, a family connection with Sir William Upjohn, whose medical career at the Royal Melbourne spanned a period of 60 years, and a short period as clinical assistant at the Royal Melbourne, may have led him to believe he could make the necessary connections to carry out one of his principal tasks - that of aligning the facilities he was to develop at Greenvale with one of the acute hospitals.45
Wallace may also have been excited by the possibility of being associated with the project so enthusiastically described by the Hospital and Charities Commission, of developing Greenvale as the foremost institution of its kind in Australia. Perhaps he foresaw the opportunity to develop the institutional setting he was to advocate some years later, where doctors tended to the ‘vegetable patch’ of chronic disease so disparagingly regarded as clogging up the acute hospitals. It was, he said, more important for doctors to investigate these more mundane conditions rather than ‘many of the acute conditions under investigation today’, so the elderly would receive more effective care and doctors could be trained more effectively and usefully. David Wallace formed his views at the Hammersmith Hospital, where some of the patients were left over from the institution’s Poor Law Infirmary days. Doctors began to investigate the chronic respiratory disorders they found there and ‘completely altered the understanding and management’ of them.46 If indeed this was Wallace’s ambition, he was soon disillusioned by his dealings with the Commission and his committee of management, and resigned three years later.47 His successor, Eloise Lucas, was also a young doctor at the
45 Obituary, MJA, vol 1, 1980, p.40-41. Wallace did eventually succeed in establishing a link with St Vincent’s Hospital and was given a position in Professor Hayden’s Unit although not as a member of the medical staff of the hospital. Minutes Meeting Committee of Management Greenvale Village, 25/7/58. 46 D. C. Wallace, ‘Changes in Educational and Living Standards (ii)’, in Medical Practice and the Community, eds R. G. Brown & H. M. Whyte, Australian National University Press, Canberra, 1970, p.131-132. 47S. Wickham, ‘Greenvale From Isolation to Centre, A History of Greenvale Centre’, unpublished manuscript held in the Library of Melbourne Extended Care and Rehabilitation, (formerly Mount Royal Hospital). Possibly the position at Greenvale was indeed a stage along the road to Wallace’s ultimate objective – physician in a provincial city, D. Wallace, Joseph Coles: A Country Doctor, nd, no publisher, p91.
133 beginning of her career, who, after some years at Greenvale went on to qualify in psychiatric medicine.48
Collin Robjohn was another who found the possibilities of establishing a geriatric service exciting. He was appointed medical superintendent at the Queen Elizabeth Home in Ballarat, and commissioned to introduce rehabilitative treatment into the institution. Up to this point local medical practitioners had provided medical care on a sessional basis for the 600 inmates. When he applied for the position, he had been in general practice in South Australia after returning from China where he had worked with the London Missionary Society. Life as a suburban GP failed to provide the satisfaction he looked for in his work and he felt he had lost the sense of vocation that had imbued his work in China. The challenge of developing rehabilitative facilities at Ballarat soon revived that sensation. When he left Ballarat, to avoid appearing to condone a drive for contributions for a building program, he continued his missionary role providing rehabilitative services for infirm old people as Director of Rehabilitation at Aldersgate Village, an institution for the aged run by Wesley Central Mission in Adelaide.49
If younger doctors failed to find sufficient openings for developing a medical career in establishing geriatric units, older men brought different expectations and, it appears, were disposed to make the best of the circumstances they found. Most of the other appointments made to the positions of geriatrician and geriatric medical officer, in the period around the late 1950s and early 1960s were usually older men, general practitioners in the latter part of their careers. Cecil Ashley has already been mentioned as the general practitioner appointed to develop the geriatric unit at Caulfield Convalescent Hospital. At the Cheltenham Old People’s Home, E. A. Eddy, another GP, was appointed medical superintendent. Shortly after, he encouraged Horace Tucker, one of his golfing partners to join him on the medical staff. Tucker was a local GP who, due to the effects of war service, found it difficult to cope with a busy practice. He found a new lease on life in taking on this work despite
48 The evidence for Lucas’ career is taken from entries in the Australian Medical Directory in the years following her time at Greenvale. 49 C. Robjohn, My Several Lives, H. C. Robjohns, Marrayatville, South Australia, 1988, p.88-95.
134 the disparaging remarks of his friends, and was later proud to be associated with the early days of geriatrics as medical work in Victoria. In time Tucker was also appointed medical superintendent.50
Reordering Old Age Infirmity The doctors who took positions as geriatricians came into contact with a range and depth of infirmity that few of their colleagues saw in everyday work. This is not to suggest that the inmates of the benevolent homes were exceptionally badly treated or accommodated. Although the institutions were drab and shabby, there is no reason to believe that, like their counterpart in the Public Assistance Infirmary when Marjory Warren first encountered them, they were not, in general well fed and clean.51 However, accepted practices whereby the poor and infirm aged had to be grateful for what they were given, were challenged by the introduction of an active medical role into the institutions, with specific techniques of treatment and specified standards of accommodation and nursing care.52 Collin Robjohn was surely not alone in feeling a revived sense of vocation as he confronted his task; old age infirmity on this scale would have stirred the most phlegmatic of souls to ‘do something for these people’ as one practitioner put it.
In all the homes, to varying degrees, new accommodation was added (some of it for ambulant patients, some for long-term care), and old wards were renovated.53 Wards, instead of being distinguished according to whether the inmates were bedridden or ambulant, were reorganised
50 When he told friends of his change of direction they responded with remarks along the lines , ‘What … are you doing out there? … getting mixed up with those dreadful old people …’. Transcript of Oral History of Kingston Centre, Ref 3/93.. 51 Warren, op. cit. 1946, p.841. 52 The difficulties in converting a custodial care mentality to a treatment oriented approach may be discerned in the comment noted in the records of meeting of the consultative committee overseeing the planning and building of the geriatric unit at Mount Royal, that the plans submitted by the superintendent of Mount Royal, Colonel Elliott, indicated an inadequate understanding of what was required in a treatment setting, RMH Archives/Managers Correspondence/Medical Matters 1/vol 15. No details were given but an indication of what the committee may have referred to may be found in notes by Elliott of a conversation between him and the Hospitals and Charities Commission architect to the effect that old people liked the large wards because there was plenty going on and, further, that special rooms for the dying were not necessary. The old, he noted, were used to their fellows dying amongst them, VPRS 4523/P1/260/2242. 53 While a certain amount of new building went on, possibly depending on the resources individual institutions were able to call upon in addition to the subsidies provided by the Hospitals and Charities Commission, new facilities existed amongst some very old and dilapidated buildings. The Commission, in the interests of economy encouraged the use of
135 according to treatment regime; that is: geriatric units or rehabilitation wards for patients undergoing straightforward restorative treatment with the expectation of discharge; longer term rehabilitation wards; assessment wards where newly admitted patients were examined prior to being allocated to the appropriate section; and wards where long-term care was provided. All the institutions continued to provide for ‘well’ old people in the form of hostel or dormitory style accommodation. Day Hospitals were established, often in converted local halls to provide restorative treatment on an outpatient basis thus making it possible to treat without admission and to maintain post-discharge supervision.54 Although there was room for idiosyncrasy in how each committee of management approached the project of expanding the facilities of its institution, changes were subject to a degree of standardisation through the subsidies provided by the Hospitals and Charities Commission. In the course of the 1960s, the commonality imposed by these incentives led to a reclassification of the benevolent homes as Special Hospitals for the Aged, or Geriatric Hospitals as they were commonly known. Requirements for change of status included the provision of daily medical attention, and specialist geriatric medical attention when required; the provision of trained senior nursing staff who were to be available day and night; approved facilities for nursing the sick; training programs for nurses aides and the appointment of therapists and the provision of chiropody services.55
In the reconfigured ‘benevolent’ setting, medical practitioners had the opportunity to develop a specific form of medical expertise related to the management of old age infirmity.56 At the first public discussion of the role of the geriatrician, Graeme Larkins pointed out that there was nothing new about the methods used in treating disabled old people. The novelty lay in providing this treatment with the aim of keeping them ‘active and healthy functional members of the community instead of merely providing
existing buildings wherever possible, Annual Report Hospitals and Charities Commission 1953-54. 54 D. H. Blake, ‘A Day Hospital for Geriatric Patients: The First Twelve Months’, MJA, vol 2, 1968, pp.802-804. 55 VPRS 4523P1/382/3167. These conditions were noted in relation to the change in status of the Bendigo Benevolent Home. 56 I have emphasised the association between the aged and these institutions because care of the aged was the stated, formal objective of the institutions. Their wards did however, also accommodate younger adults suffering from chronic disease and disability whose needs were the same as their older companions.
136 them with comfortable custodial care’.57 It would have come as a shock to the first set of patients admitted for rehabilitation treatment to find they were the objects of such intense attention. All their experience would lead them to expect that to have a stroke, to fracture a hip joint or have a leg amputated, to be diagnosed with Parkinson’s Disease, or to be afflicted with the crippling and debilitating pain of arthritic joints, would mean spending the remainder of their days confined to bed or, at best, a wheelchair. The prospect for those without any resources was grim.58 They faced the ignominy of going into ‘a home’, to see out their days in the dreary routine of bed-care provided by overworked attendants, in wards shared by forty or more of their peers, many of whom would have already sunk wordlessly, others more raucously, into an indeterminate condition between life and death.
In the geriatric unit at Mount Royal by contrast, infirm old people found themselves, not in the long wards with forty or fifty others as they may have expected, but in the hospital version of a domestic setting.59 Beds were arranged in small units of four or six, with cupboards nearby for the everyday clothes that patients were expected to wear during their stay in the unit. Bathrooms were close by, where, depending on their disabilities,
57 Larkins, 1956, op. cit. p.23. Larkins was correct in saying there was nothing new about the methods of rehabilitation – many of these techniques were developed during wartime to enable maimed service personnel to make the most of their capacities. In relation to the disabled aged, restorative methods had an even longer history as G. F. Adams notes in his text Cerebrovascular Disability and the Ageing Brain, Churchill Livingstone, Edinburgh, 1974. Adams writes that Sir Richard Gowers, an English physician, described methods similar to those publicised by Marjory Warren, in his textbook published in 1888, A Manual of Diseases of the Nervous System. He continues with the point that Gower’s principles of treatment and ‘profound first-hand knowledge’ were forgotten in the first half of the twentieth century as ‘palliative treatment of the residual disabilities of cerebrovascular disease became less important than the dramatic successes of curative treatment …’. p.6. 58 This group did not necessarily include those who had been poor all their life. Others with sufficient resources to manage while they were well, were not able to pay for the degree of care they needed following a stroke for example. Lack of family to assist them was also a factor in their need to call upon public assistance, Hutchinson, op. cit. p.143. 59 In emphasising Mount Royal in this brief account I am contributing to the situation, often regretted by the other institutions, where their achievements may have been overlooked because Mount Royal assumed and was usually granted precedence amongst this group of state hospitals. In my account of the development of rehabilitative expertise, Mount Royal is prominent simply because the doctors who developed the role of geriatrician there were more inclined to document their work, thus making it accessible to the historian. The reconfiguration of the benevolent home environment as a hospital version of an appropriate domestic setting for the infirm aged is an extension of the process Weindling discerns underlying the emergence of the ‘scientific’ hospital, in which ‘hospitals and sanitoria developed to provide an ideal type of domestic environment’ as an antidote to mass urban poverty, P. Weindling, ‘From Infectious to Chronic Diseases” Changing Patterns of sickness in the Nineteenth and Twentieth Centuries’, in Medicine in Society, Historical Essays, Cambridge University Press, Cambridge, 1992, p.315.
137 they would relearn the art of bathing and dressing. In yet another section, there was a dining room where patients were expected to take their meals and engage in the sociable interaction that was so essential in maintaining a mental orientation towards community life. In addition, there were specified areas for occupational and physiotherapists to provide therapy directed towards developing the necessary skills to negotiate these activities despite disabilities.
For those whose lives had already been reduced to the confines of bed, the dissection of every aspect of their disability must have been a confronting experience, possibly a mixed blessing in view of the efforts they were required to make if they wished to alter their bed-bound condition.60 On admission to the Geriatric Unit at Mount Royal, each patient was the focus of attention as physician, social worker, therapists and nurse attempted to gain ‘full knowledge of the patient, his nutrition, his environment, his aspirations and the foundation of residual capability’ on which to base restorative treatment. Not surprisingly, it was often difficult to motivate patients who ‘… when first seen are lacking hope: they feel that nothing can be done for them and must be convinced that attempts at improvement are worthwhile.’61 Group therapy was particularly helpful in assisting such patients to see that what could be done for others may also be done for them. It was, therefore, especially important to provide rehabilitative treatment in an area well separated from the wards where long-term care was provided, in order ‘to concentrate the thought of the patient on the idea that they can and will get well’.62 The emphasis on the need to separate the rehabilitation unit from the long-term care wards is an indication of the extent to which the introduction of restorative treatment for infirm old people contested prevailing ideas about what it meant to be old and disabled. In managing the geriatric unit at Mount Royal, Robert Butterworth adopted the policy of accepting any patient who was thought to have ‘even a slender chance of benefiting from intensive rehabilitative treatment’. In ‘borderline’ cases he sought the opinions of nursing staff, therapists and almoner (social worker).63
60 L. Yapp, Physiotherapy in R.F. Butterworth, ‘The Geriatric Unit at Work’, Geriatrics Conference 1958, Geriatrics Conference, op. cit. pp.13-24. 61 Butterworth, 1958, op. cit. 62 Larkins, op. cit. p.24. 63 Butterworth, 1958, op. cit.
138
There may indeed have been ‘nothing new’ about the character of the rehabilitative techniques used in the geriatric units. However, their introduction did entail a complete reversal in the prevailing view that bed- rest was the most appropriate response to old age sickness and disability. Marjory Warren had described the debilitating the effects of bed-rest on the aged body in terms of compounding existing infirmities, and providing the conditions in which additional deformity and disease could develop. Put to bed, she continued, the patient ‘rapidly loses morale and self– respect’, it being clear that there is no hope of recovery and all independence gone. The temperament becomes ‘apathetic or peevish’, even aggressive, and laziness and faulty habits develop, perhaps even incontinence. Confined to bed the inactive aged body undergoes detrimental physiological changes that are difficult to reverse – bed sores, postural deformities, contractures, and ‘disuse atrophy of the lower limbs’.64 Where the objective of rehabilitation treatment for other adults was to restore the capacity to work and a stable level of independence, for the infirm elderly, it was related to the capacity to participate in everyday life: to get about, to feed oneself, to wash, dress, and be sociable. In addition, restorative treatment was provided from a perspective that recognised that this capacity for participation was likely to change from time to time as new illnesses or injuries were superimposed upon existing disease and infirmity. This recognition of the importance of activity in maintaining well-being in infirm old people underpinned John Lindell’s idealistic objective of ‘docketing’ each vulnerable individual in the region served by a geriatric unit.65
Paralysed bodies, whether from stroke or some other degenerative disease, were inspected closely by geriatrician and physiotherapist in order to identify unimpaired muscles so they might be strengthened through exercise in order to reinforce those affected by injury or disease.66 Bodies long confined to bed, having lost strength and the capacity for balance, had to learn anew how to move about, beginning by rolling from side to side on the floor and crawling, until gradually reaching the point of being
64 Warren, 1950, op. cit. 65 VPRS 4523 p2/947/72/1. 66 L.T. Wedlick, ‘Physical Therapy in Geriatrics’, Geriatrics Conference, 1957, cit. p.13- 14, Yapp, op. cit.
139 able to remain upright with the assistance of technical aids. When individuals had been confined to bed or chair for a protracted period of time and inactive limbs had contracted, it took time to distinguish damage associated with neurological malfunction from that imposed by lack of use, and even more time to strengthen long disused muscles. Time also had to be allowed for patients’ lack of confidence to be gradually replaced by the realisation that some independence was possible. Likewise, mental confusion in a newly admitted patient could not immediately be attributed to permanent changes; it was likely to clear given time, since ‘often apparent poverty of intellect is due mainly to loss of hope and will improve rapidly with active attempts to help.’67 Such tolerance of mental confusion was based on a selective process through which patients whose ‘poor intellectual capacity, undue loquacity, inability to concentrate, (and) spatial disorientation’ had already ensured they were considered unsuited for restorative treatment.68
The foregoing comments must not be taken to mean that geriatricians saw no role for themselves in providing services for the mentally disturbed. At the 1961 Geriatrics Conference John Shepherd, medical superintendent of Mount Royal said that 25 to 30 per cent of potential patients for the services he offered at his hospital suffered from some degree of mental deterioration. The problem he faced in providing services available to all likely candidates for custodial care was that he could not admit patients immediately as his institution continued the practice of admitting patients on the basis of position on the waiting list.69 Psychiatrists in Victoria were also beginning to develop services for this group of patients, and in keeping with the division of medical labour between mental and physical illness, this aspect of medical care for the elderly will be dealt with separately in the following chapter. It was one of these psychiatrists, G. V. Davies, who published a study in 1961 showing that old people were badly done by in a hospital system based on this division. In acutely ill elderly patients, mental and physical disorders could only be disentangled
67 Butterworth, 1958, op. cit. 68 Larkins, op. cit. 1956, p.24. 69 Geriatrics Conference, 1961, p97-98, Geriatrics Conference, 1958-1966, op. cit.
140 following prompt admission and investigation – it was this service that Shepherd wanted to be able to offer.70
The Geriatric Community The beginnings of a local body of clinical knowledge, techniques and aids began to emerge as doctors, nurses, therapists and social workers focused on a previously undifferentiated mass of old age infirmity. Some textual material was already available. The doctors who developed the field of geriatrics in Britain had, since the late 1940s, begun to publish on topic in journals and medical texts.71 In the United States occupational and physiotherapists developed aids and techniques in the rehabilitation institutions established by philanthropic bodies as a means of dealing with the problem of chronic illness in all age groups.72 Robert Butterworth, geriatrician at Mount Royal, was notable amongst the small group of medical practitioners who took on the role of ‘geriatrician’ in Victoria, for disseminating his work in the form of journal articles.73 For most Victorian practitioners the principal forum for disseminating their new knowledge was the annual Geriatric Conference sponsored by the Hospitals and Charities Commission. These conferences, organised in turn by the Special Hospitals for the Aged, were meeting places not only for the various groups involved in the ‘geriatric’ enterprise in Victoria but
70 G. V. Davies, ‘The Relation of Physical and Mental Disease in Later Life’, MJA, vol 2, 1961, pp.152-154. 71 Exton-Smith, 1955, op. cit. provided a handbook that combined all the facets developed in the early work of the geriatric departments in British hospitals. The first edition of Trevor Howell’s Old Age, Some Practical Points in Geriatrics, H. K. Lewis & Co. Ltd, London, was published in 1944 but it was not reviewed in The Medical Journal of Australia until the second edition appeared in 1950. As noted in chapter two, Marjory Warren’s work was recognised in the 1940s in anonymous articles in The Medical Journal of Australia, and J. S. Sheldon’s Social Medicine of Old Age, was reviewed in 1948 soon after it was published. 72 In the early 1950s in the United States a number of professional bodies came together to form a Commission on Chronic Illness - the American Hospital Assoc, American Medical Assoc, American Public Health Assoc and American Public Welfare Assoc. Its findings were published in four volumes in the course of the 1950s. In the US therapists played the prominent part in developing aids and techniques. The manual published by the Institute of Physical Medicine at the Bellevue Medical Centre at New York Hospital was used by therapists at Mount Royal. With the exception of a small number of physicians, Dr Howard Rush for example, doctors in the US showed little interest in civilian rehabilitation, Gritzer & Arluke, op. cit. 73 R. F. Butterworth, ‘Localised Oesophagitis Due to Drugs’, MJA, vol 2, 1958, p.419-420 ‘The Burning Skin Syndrome, Treatment with Hydroxychloroquin’, MJA, vol 2, 1960, p.460-461. ‘ “Painful Leg” Following Strokes’, MJA, vol 2, 1963, pp.880-882, ‘Pneumatic Device for Correcting Knee-Joint Contractures’, MJA, vol 1, 1965, pp.714-715. Annual reports for Mount Royal in the years 1960-63 also list articles by Butterworth published in General Practitioner of Australia and New Zealand, on the topic of knee joint deformity, the management of stroke in general practice and incontinence in the elderly. Butterworth
141 also for those in the other states.74 In addition, they brought Australian doctors together with the British practitioners whose work provided their model. Marjory Warren visited Australia in 1958, Lionel Cosin followed her in 1961, and W. F. Anderson in 1968.75
Even in the earliest attempts to develop geriatric services, it was made clear that the restorative process entailed combining the skills of doctors, nurses, therapists and social workers. Medical knowledge of bodily systems was combined with the skills of other health professions - in a manner not usually seen in the general hospitals - to enable an elderly amputee, often afflicted with multiple illnesses, to use an artificial limb, or to restore independence in a stroke patient to whatever degree possible.76 Ideally clinical skills combined with the technical skills of physiotherapists to strengthen muscles devise aides to mobility; with the skills of occupational therapists to develop approaches to the tasks of everyday life to encourage patients to persist through what was often a slow process of bathing, dressing and eating; with the social worker’s knowledge of a patient’s home conditions so he or she could be returned to an environment where their hard-won independence would not be undermined. In his first presentation at a Geriatrics Conference in 1958, Robert Butterworth acknowledged the importance of his co-workers by bringing them along to describe their contributions.77 In practice,
also contributed an article titled ‘Gerontology’ to Science Review, no 15, 1960, a publication of Melbourne University Science Club. 74 Annual Report Hospitals and Charities Commission, 1955. John Lindell gave credit to Elizabeth Johnson for the idea of the conferences and they continued from 1956 into the 1970s. The educative role of the Commission was fulfilled in a number of ways, these conferences being only one of them. Others included awarding bursaries for various categories of hospital staff to enable them to enter professional training with a higher level of schooling, providing scholarships to enable managers and superintendents to gain tertiary qualifications in this field, establishing the Mayfield Centre to provide training courses for hospital staff, Inall, 1971, op. cit. p.49. 75 Collin Robjohn referred to Warren’s visit and how encouraging she was, Robjohn, op. cit. p.89, see Geriatrics Conferences 1961 and 1968, Geriatrics Conference 1956-1966 op. cit. and Geriatrics Conference 1967-1976, Hospitals and Charities Commission, Spring St Melbourne, nd. 76 In the public hospitals doctors were inclined to assume that the poor peripheral circulation that made amputation necessary would also ensure that it would be unlikely that an artificial leg could be successfully attached to the stump. Consequently the operation was not done with this in mind and there were further difficulties arising from the lapse in time in these early days between amputation and the attempt at rehabilitation. The work done in the geriatric units challenged the assumption that elderly amputees were not candidates for artificial limbs. The doctors and technicians in the geriatric hospitals were proud of their inventiveness in developing cheap, temporary prostheses that made it possible to give patients the opportunity to regain mobility, see Geriatrics Conferences 1958, 1959, 1960, Geriatrics Conference 1956-1966, op. cit. 77Butterworth, 1958, op. cit., p.13-14.
142 however, this ideal was achieved only patchily. Therapists were in short supply, as were trained nurses and they were no more inclined to find the work in these former benevolent institutions attractive than were medical practitioners.78
The activity of nursing the infirm aged was transformed with the introduction of the role of geriatrician. Graeme Larkins emphasised the importance of the nursing role in his outline of rehabilitative treatment for infirm old people. Where the measure of care provided by untrained attendants was how much they did for their charges, in the environment of restorative care the measure was how much the nurse was able to encourage the patient to do for herself.79 The nurse needed to understand the contributions of the different therapists to be able to reinforce them outside treatment sessions. The relationship between patient and nursing staff was fundamental to the success of restorative treatment because it was continuous, whereas contact with therapists was intermittent.
In addition, the principle of encouraging activity in order to prevent illness and disability was introduced into the nursing of patients who required long-term care, giving the work of nurses in the long-term wards a technical aspect. The avoidance of pressure sores through regular changes of position and ‘pressure area treatment’; the treatment of incontinence by means of routine measures; the recognition of the need for attention to fluid intake and nutrition; all of these combined some degree of technical understanding of the physiology of the aged body and a trained approach to nursing care. There were special techniques to be learned but it was also a matter of disposition. The geriatric nurse, like the geriatric physician described by Trevor Howell, needed to have a special therapeutic interest in this group of old people. There was no place for the nurse who took on the work as a matter of duty to a neglected group of patients, or because it was considered less demanding than other types of nursing.80
78 The Age, 24/4/71, quoted the Chairman elect of the Hospitals and Charities Commission, as proposing establishing a ‘middle level’ of qualified therapists as a means of alleviating the general shortage. 79 G. Larkins, 1956, op. cit. p.24. 80 R. Tabbner, ‘Geriatric Nursing’, Geriatrics Conference, 1960, Geriatrics Conference 1956-1966, op. cit. p.75ff.
143 The importance of the nursing role was acknowledged in the award of a travelling scholarship, similar to those awarded to the first ‘geriatricians’, to Ray Tabbner, registered nurse and Deputy Matron at Mount Royal.81 When the geriatric unit at Mount Royal was being planned, it was proposed that nursing staff would come from the ranks of the trainee nurses at the Royal Melbourne Hospital, as part of their general training experience.82 This did not happen, possibly because of the general shortage of both trained and trainee nurses in the early 1950s. The shortage was exacerbated by the overall expansion in the numbers of hospital beds at the time, including the ‘hospitalisation’ of the benevolent homes. In response to this situation the Commission established a system of training at a lower level than the General Trained Nurse - that of the Nurses Aide - and the Geriatric Hospitals thus became training schools for their own staff.83 The question of equipping trained nurses to develop and supervise this new nursing role was tackled by establishing a postgraduate course of training at Mount Royal in the late 1960s.84
The Geriatric Patient The ‘geriatric patient’ was defined at the annual Geriatrics Conferences through the display of representative patients who demonstrated the product of the combined activities of doctors, nurses, therapists and institutional administrators. Depending on the skills of the doctor presenting these living examples, the appearance of rehabilitated patients was both an illustration of the possibilities of restorative treatment and an opportunity to teach the principles of an active approach to the medical care of the elderly patient.
81 J. Uhl, op. cit. p.185-186. A report on this tour was presented at the 1959 Geriatrics Conference, R. Tabbner, ‘Care of the Elderly Ambulatory People Overseas’, Geriatrics Conference 1956-1966, op. cit. Up to this point it could not be taken for granted that the Matron of Mount Royal would be a trained, registered nurse. 82 RMH Archives/Managers Correspondence/Medical Matters/1/ vol 15. 83 J. & B. Bessant, The Growth of a Profession, Nursing in Victoria, 1930s –1980s, La Trobe University, Press, 1991, pp.71-73. 84 J. Uhl, historian of Mount Royal Hospital, dates the first postgraduate course in geriatric nursing to the 1980s. However, Marion Shaw, the English nurse who arrived in Victoria in the late 1960s, and went on to become an officer in the Geriatric Division of the Hospitals and Charities Commission, says she participated in a postgraduate course at Mount Royal in the geriatric unit, beginning in April 1969. Personal communication from M. Shaw, March 1997. A reference to a post-basic nursing course in a talk given at the 1969 Geriatrics Conference by Kathleen Wilson, Principal Nurse Educator at Mount Royal, confirms this, Geriatrics Conference 1967-1976, op. cit. p.74. A lecture published in the MJA, in 1965, given by Sidney Sax to the second postgraduate nursing course at Concord Repatriation General Hospital, suggests an earlier date for the introduction of postgraduate
144
Thus the account of restoring mobility in eighty-three years old Miss B, whose leg had been removed because of arteriosclerotic gangrene, brought out the need for vigilance in the prevention of bedsores.85 Having been confined to bed for some time before her admission to Greenvale, a sore had developed on the heel of her remaining foot and the noting of this point was accompanied by a discussion of the methods of preventing and healing such sores. When she was admitted she had lost all interest in life, ‘she was old, she’d lost her leg, attempts had been made to get her on her feet, they’d been unpleasant to her and she’d given up hope.’ She was prepared to spend what little time she had left sitting in bed waiting to die. Had a rehabilitative approach been established practice in the public hospitals, she may not have experienced this degree of despair.
At Greenvale the concerted efforts of therapists and nurses encouraged her to make the effort required. An artificial limb was devised, - ‘nothing much to look at’ - but she walked on it and ‘she’ll walk off with something that’s well, quite passable for an artificial leg’.86 Once she had gained some independence at Greenvale she was transferred to a halfway house, where having got to the stage where she was looking after herself to a certain extent in an institutional setting, she could then try herself out in a more domestic environment.87 The hope was that she would return to her little house in the inner Melbourne suburb of Richmond after it had been checked to see what alterations were necessary to assist her to manage.
The rehabilitated patients exhibited at the Geriatrics Conferences were, however, still a minority in the day to day work of geriatricians. On the whole, the extent of deterioration in the patients referred to them ‘after everyone else has had their go’ ensured that the patients who came into training in this field in New South Wales, S. Sax, ‘Geriatrics: The Subject Defined’, MJA, vol 1, 1965, pp.26-28. 85 Case presented by Dr David Wallace at the 1960 Geriatrics Conference, Geriatrics Conference, 1956-1966, op. cit, p.97-98. 86 Wallace was, it seems, proud of what he, and his technician, were able to do cheaply and effectively. They could make a light, temporary prosthesis for the cost of fifteen to twenty pounds rather than the hundred or so needed for a conventional artificial leg. Other solutions were even cheaper. Two or three pounds could provide a bucket and a peg leg, also ‘rockers’ were devised for double amputees to provide a degree of mobility within their home, with a wheelchair being used outdoors, Geriatrics Conference 1958-1959 for examples, Geriatrics Conference 1956-1966, op. cit.
145 their care were, in the main, candidates for long-term care, with limited prospects for effective rehabilitative treatment.88 Moreover, the continued use of buildings erected in the nineteenth century, in the interests of economy, to accommodate the unstemmed flow of infirm aged and the chronically ill, ensured the persistence of aspects of the ‘benevolent asylum’ era, particularly overcrowding and dilapidation. The foregoing account of innovative techniques, the inventive fabrication of aids and the air of optimistic cooperation amongst medical practitioners, nurses, social workers and therapists thus provides a somewhat idealistic picture. At best it was characteristic of the early years in the establishment of the Geriatric Hospitals. After the mid-1960s the medical work of geriatrics was defined in terms of the institutions in which it was located – institutions which provided long-term care for individuals, most of them elderly, with nowhere else to go. Despite the great hopes of the early ‘geriatricians’, the ‘geriatric patient’ in Victoria was still barely distinguishable from the impoverished benevolent home inmate. David Wallace made the association between geriatrics and poverty clear when he defined it as the medical management of old people who, in addition to physical and mental afflictions suffered from what he referred to as ‘social infirmity’. The combination of ‘lack of money, lack of friends and relatives who can or will care for the patient … and general frailty which makes it hard for an old person to continue to battle on leading an independent existence.’89
Obstacles to Defining ‘Care of the Aged’ as Medical Work One obstacle to the development of the geriatrician’s role as a provider of medical services rather than the supervisor of institutional care, was the condition under which doctors in the Geriatric Hospitals gained access to
87 Greenvale had a half-way house at Clayton. The importance of the half-way house in restorative care was discussed by Graeme Larkins in his first contribution to the Geriatrics Conference in 1956, ‘Modern Methods of Rehabilitation’, op. cit. p.25. 88 This telling phrase has been taken from notes for a lecture by Dr John Shepherd amongst his personal papers. The lecture ‘A Total Geriatric Service’ was given in 1971. It is substantially, a restatement of the aims John Lindell had identified when the first geriatric units were established, an indication of the extent to which the original intentions had not been realised. 89 D. Wallace, ‘Geriatrics Overseas’, MJA, vol 2, 1959, p.40-42. Wallace quoted Lord Amulree in this definition. Amulree was an English physician and official in the National Health Service, and author of the book Adding Life to Years, The National Council of Social Services, Bannisdale Press, London, 1951. While encouraging the introduction of geriatric departments into acute hospitals, Amulree opposed the creation of a new clinical
146 their patients. The majority of patients came from the public hospitals so it was the relationship between the geriatrician and hospital medical officers that was the source of greatest difficulty. It was noted above that the ‘geriatrician’ occupied a place in the provision of hospital services similar to that of the convalescent medical officer. In practice, however, the geriatrician had the same difficulty in controlling the referral of patients from the acute hospitals as did the earlier convalescent MO.90 As a rule, patients in the public hospitals were brought to the attention of the geriatrician after a period of treatment when it was clear that nothing more could be done. Because geriatricians had no role in acute care, they had no access to patients in the early days of their treatment, so it was more by good luck than good management when they were referred patients who were candidates for successful rehabilitation. The lack of a registrar to establish an immediate connection between potential candidates for custodial care and the geriatric service was an important factor in this situation.91
Robert Butterworth hoped to circumvent some of the problems posed by the lack of direct involvement in acute medical care by geriatricians by setting aside a couple of beds in the geriatric unit for acute stroke cases, so their restorative care could be integrated into their overall treatment. He was unable to realise this ambition. His role as clinical assistant at the Royal Melbourne did not encompass the provision of acute care and, in addition, because of the pressure to take patients already waiting to be discharged from the hospital, it would have been very difficult to maintain the empty beds. In reality he was dependent on other hospital doctors to refer patients to him and it was not very long after the geriatric unit was established that he had cause to question their judgement of suitability. At a meeting of the consultative committee soon after the geriatric unit specialty as he believed the medical care of the elderly did not require any special approach on the part of doctors other than an interest in this group of patients. 90 Ford, 1996, op. cit. pp.88-90. 91 Part of the initial agreement between Mount Royal and the Royal Melbourne Hospital was that a registrar would be appointed to the geriatric unit. In fact a couple of doctors were interested in the beginning but delay in opening the unit meant they had moved on to other employment. Then RMH found it difficult to replace them, and the position of registrar was not regularly filled. This is not surprising in view of the fact that such a position had no point of connection with the training of physicians, RMH Archives/Medical Matters/No 1/ 28, meeting of consultative committee 19/2/59. The lack of a formal connection between the other Geriatric Hospitals and an acute hospital meant
147 opened, Butterworth cautiously noted ‘the slight tendency for RMOs to dump patients on us’.92 He also feared the opening of a rehabilitation hospital in the Royal Melbourne’s region would mean the patients referred to the Geriatric Hospitals were likely to be very old and infirm.93 Butterworth’s sad observation that ‘we appear to be getting many decrepit cases referred for admission … not all rehabilitation cases attend the weekly Clinic’, illustrates the situation of the geriatricians within the Victorian hospital system.94 His remark is the more telling since he was in a better position to exert control over his work than any of his fellow practitioners. He was a member of the consultative committee that oversaw the ‘cooperation’ between medical staff at Mount Royal and the Royal Melbourne Hospital, he had an official position on RMH staff and an outpatient clinic.95 Nonetheless he still appears to have had little control over the referral of patients and there is no reason to think that the experience of the other geriatricians was any better.
On the whole, general practitioners in the community were as ignorant as their specialist colleagues in the public hospitals of the treatment offered in the Geriatric Hospitals. Robert Butterworth played his part in educating
there was not even the possibility of a registrar to make a connection between the acute wards and the geriatric service. 92 RMH Archives/Medical Matters/No 3/24. 93 See Chapter Two. Two small rehabilitation hospitals were established outside the acute hospitals in the early 1960s, staffed by part-time medical officers. One was located at Hampton, in a former annexe to the Childrens’ Hospital. L. Wedlick, formerly medical officer in charge of the physiotherapy department at the Royal Melbourne Hospital, was appointed honorary Director to establish the hospital, L.T. Wedlick, ‘Development of a Rehabilitation Centre’, MJA, vol 1, 1961, pp.338-340. The other rehabilitation hospital, the one Butterworth referred to, was located in the former colony for epileptics, the Royal Talbot Centre, S. Steele, A Road to Rehabilitation, North Eastern Health Care Network, Victoria, Australia, 1996, L.T. Wedlick, A Doctor’s Life (Odyssey) Leigh T. Wedlick, nd, p.47. 94 RMH Archives/Managers Correspondence/Medical Matters/No 1/24/1969. Dr Eloise Lucas who followed David Wallace as geriatrician at Greenvale, provided another view of this situation when she remarked at a committee of management meeting that Greenvale was in an unsatisfactory position taking patients from the Royal Melbourne because the geriatrician at Mount Royal (Butterworth), being in charge of the clinic at RMH, ensured that the ‘better type’ of case went to Mount Royal. Minutes Committee of Management, Greenvale Village, 8/6/62. 95 The relationship between Mount Royal and the Royal Melbourne was an uneasy one. As early as 1960, a meeting was called between representatives of both institutions and the Hospitals and Charities Commission, to try to resolve the problems posed by the Royal Melbourne regarding Mount Royal, even the Geriatric Unit, as a place to which chronic, long-term patients could be cleared, and Mount Royal choosing to exercise its right to take patients from any source. Note regarding meeting, 7/4/1960, by medical superintendent, Mount Royal, from the personal papers Dr John Shepherd.
148 GPs by providing demonstrations and lectures in his unit.96 A special interest group was formed in the very early 1960s within the Victorian Branch of the British Medical Association but there is no record of any promotional activities undertaken by this group.97 E. A. Eddy, medical superintendent during the early sixties at Cheltenham Old People’s Home (Kingston Centre), tackled the problem by placing a notice in one of the Monthly Papers put out by the AMA, describing, for the benefit of local GPs, the restorative treatment now available at his institution. His successors were also unsuccessful in attracting the interest of their local colleagues, a situation Lloyd Jago accounted for by the tendency for general practitioners to be excluded from the hospital system in general.98
While individual GPs may have been sufficiently interested to follow up Butterworth’s demonstrations or to attend the occasional meetings and lectures advertised in the AMA’s Monthly Papers, there was no formal organisation providing an induction into the methods of restorative treatment being developed in the Geriatric Hospitals. Also, if a GP, who confronted with a patient who had suffered a stroke or whose arthritis was making it increasingly difficult to get about, mentioned admission to a Geriatric Hospital for rehabilitative treatment, the suggestion was likely to be received unsympathetically. The view expressed by Horace Tucker’s friends, when they asked why he was involving himself with those dreadful old people, was most probably representative of the general community perception of the Geriatric Hospitals.99 It highlights the point that the people who did receive the benefit of restorative treatment were, on the whole, those who had no choice, being in the public hospital with nowhere else to go. There was a possibility of change when the hospital insurance funds recognised rehabilitative treatment for the purposes of claims by patients, but this could only influence the type of patient
96 An obituary for Butterworth in the Annual Report for Mount Royal, 1973, highlights his educational activities and his inventiveness in developing devices to facilitate rehabilitation. 97 Annual Reports Mount Royal, 1959-1963. This special interest group was formed while the Australian medical profession was organised as state branches of the British Medical Association. The Australian Association was registered in Canberra in 1961 and began operation in January 1962 and the state branches then became branches of that association, Pensabene, op. cit. p.168. 98 AMA (Victorian Branch) Monthly Paper No 76, May, 1969. Transcript of conversation with Dr L. Jago, Oral History of Kingston Centre, 21/93. 99 See quote in footnote 32.
149 admitted for treatment once doctors and patients accepted such practices.100
There is no doubt their medical colleagues were not disposed to take the work of the geriatrician seriously. Had geriatricians been able to control admission policy in their institutions, they might have been in a better position to engage in negotiations with their colleagues in the public hospitals - if for no other reason than to better expedite the transfer of patients. However, even in their institutions geriatricians were not able to gain control over the hospital environment. Ten years after the introduction of the expanded medical role into the benevolent institutions and their reclassification as Special Hospitals for the Aged, the practice continued of admitting patients according to position on the waiting list. This in turn provided ammunition for demands for funds to provide accommodation. The committee of management at the Kingston Centre, despite the presence amongst them of a medical practitioner who could have put the case for the provision of services rather than beds, hoped to expand accommodation in the institution from around 600 beds to 1000.101 The Queen Elizabeth Home and Hospital at Ballarat was exceptional in devoting resources to a domiciliary service designed to assist potential patients to remain at home.102 Nevertheless the building virus lurked here also. Collin Robjohn, appointed medical superintendent in the late 1950s, resigned before his contract expired rather than remain and appear to condone a fund raising drive by the committee to expand the institution, a move he believed to be inimical to the provision of rehabilitation services.103
Why were geriatricians in this awkward position? Why did they not, as a group, bring pressure to bear on committees of management to change this situation? It might have been expected that the Association of Geriatric
100 The annual report for Mount Royal, 1959 notes that the Director General of Health in Canberra had given permission for patients admitted to the Geriatric Unit at the hospital, to claim on their Hospital Insurance for the fees they were charged. This situation had changed by the 1980s, see chapter seven. 101 Interview with Dr David Quinn, Transcript of Oral History of Kingston Centre, Ref 19/92. 102 Dicker, 1958, op. cit. 103 Robjohn, 1988, op. cit. p.94.
150 Medical Officers, formed in the early 1960s, would undertake this task.104 The Association, formed for the dual purpose of promoting the discussion of common problems and representing the interests of these practitioners, appears to have met for the former purpose only for a short period after its formation. The only reference to the second aspect of its role appears in a submission to the Hospitals and Charities Commission in the matter of qualifications and the terms and conditions of employment of geriatric medical officers.105 There is no indication that the Association played any further part in advancing the role of geriatrician after these early years. There is no doubt that geriatricians were not in the same favourable position to establish professional associations as the doctors who were cultivating the specialist fields that proliferated in the 1960s, in the hospitals and research units around the city of Melbourne. Geriatricians were, on the whole, isolated in institutions far distant from each other and, in comparison, their numbers were few.106
Isolation and lack of numbers, however, do not entirely explain the lack of action on the part of geriatricians to establish a more independent role as providers of hospital services. Just as influential was the absence from the ranks of geriatricians of an individual who was prepared to take on the undoubtedly difficult task of integrating the role of geriatrician into the mainstream of medical work. Instead it seems, the doctors who persevered in working in the field of geriatrics throughout the 1960s were those who, by virtue of age, gender and disposition, shared the same conservative outlook as their mostly male committees of management.107 A conservatism that led them to be satisfied with a position of some standing (such as medical superintendent), and significant, if limited,
104 A Special Interest Group was also formed within the Victorian branch of the British Medical Association but apart from a brief reference to this by David Wallace, there is no record of the section’s activities in The Medical Journal of Australia, see chapter six. 105 Personal papers Dr John Shepherd; VPRS 4523/P2/961/183-1. 106 Pensabene, op. cit. pp.163-166. 107 In the 1940s the Bendigo Branch of the National Council of Women made a direct effort to seek the nomination of a woman for the next vacancy on the committee of management of the Bendigo Benevolent Home, Cusack op. cit. p.193. There is no reason, however, to believe that the inclusion of women in the committees of management would have altered the inherent conservatism that seems to have imbued the ‘geriatric’ environment, an environment which reflected the broader society in the combination of a respect for ‘science’ and ‘progress’ with suspicion of difference and a prejudice against change, see S. Alomes, M. Dober & D. Hellier, ‘The Social Context of Postwar Conservatism’, in Australia’s First Cold War, 1945-1953, eds A. Curthoys & J. Merritt, Geroger Allen & Unwin, Sydney, 1984, pp.6-14.
151 power in the field of activity that was emerging around the provision of care for the aged.
Those who were not so disposed, resigned – for enterprising medical practitioners there were plenty of opportunities in other fields of medical work at the time.108 The role of geriatrician did not offer sufficient enticement to lure doctors into making the not insubstantial effort required to bring this work into the mainstream. It could not compare with either the technical advances that were taking place in the public hospitals, or with the resurgence of general practice that had followed the introduction of the national health scheme in the early 1950s.109 If George Rosen is correct in nominating competition as an essential factor in the development of medical specialisation, there was no competition to spur the development of geriatric medicine.110 It is no accident that the Geriatrics Conferences provide the best insight into the role of the geriatrician in Victoria because the institution-based environment displayed there, with its ethos of ‘care for the aged’ was the primary influence shaping the medical work of geriatrics. It is entirely in keeping with the direction taken by doctors in developing geriatrics in Victoria that at a conference held at Lidcombe State Hospital in New South Wales in 1965, on the topic of ‘Clinical Problems Amongst Aged Patients’, the Victorian contribution dealt with the provision of long-term care.111
108 The expansion of the hospital system in Victoria during the 1950s and 1960s provided more positions within hospitals for doctors but these were absorbed into training positions for the specialties that proliferated in the 1960s, R B. Scotton, Medical Care in Australia, Sun Books Melbourne, 1974, p.76ff. In addition, the conditions of work for physicians, the field where geriatric medicine would be located, were not so satisfactory as they were for surgeons so the numbers of physician consultants did not grow at the same rate as the numbers of surgeons. 109 Sir Earle Page, Minister for Health in the Menzies’ government and principal architect of the national health system introduced in the early 1950s, included a quote in his description of this system in which it is noted that the ‘Australian Medical Plan’ consisted of two stages, both aimed at ‘restoring the position, prestige and fullest usefulness of the general practitioner …’, Page, 1960, op. cit. p.47. 110 Pensabene, op. cit. pp.159-162. George Rosen notes that in the US and Britain, ‘the organization of special ophthalmic institutions preceded the appearance of the ophthalmologist’, it was competition amongst doctors in urban areas that was a significant factor in the development of the specialty, Rosen, 1972, op. cit. p.33. 111 Newsletter of the Australian Association of Gerontology, vol 1, no 2, 1965, p.5. Dr John Shepherd, medical superintendent of Mount Royal Hospital, gave a paper on the topic of long-term care. The question arises of why Robert Butterworth did not speak about the treatment of stroke, clearly a special interest of his. Possibly he did and the paper was not included in the report on proceedings at the conference. Possibly the medical superintendent took precedence over him. Lidcombe Hospital began as a reformatory for recalcitrant boys, then during the 1890s depression, accommodated destitute old people and the chronically sick. In 1914 it was renamed Rookwood State Hospital and Asylum and in 1943, Lidcombe Hospital. Its history was not unlike that of Mount Royal with a significant
152
If the failure of geriatricians to gain control over admission policy suggests an absence of collegiality and initiative amongst these medical practitioners, the question also arises of why the Hospitals and Charities Commission did not intervene to ensure the efficient operation of geriatric services by establishing medical control over admission policy. The Commission had, after all, been the principal sponsor of the geriatrician’s role, and geriatric services were intended to play a part in the provision of hospital services in Victoria. Why did the Commission not take whatever steps were necessary to appoint geriatricians to positions where they could influence policy?112 In the absence of any evidence on this matter it may be speculated that first, the collaborative atmosphere in which geriatric services were developed may have meant the possibility of achieving this through negotiation was never closed off. However, the lowly position of the Hospitals and Charities Commission in the bureaucratic hierarchy may have contributed to the situation. Bridget McCoppin noted, in her early 1970s study of the Commission that the health portfolio ranked low amongst ministerial offices. In the long reign of the Liberal Party (in coalition with the Country Party), that began in the early 1950s, the position of Minister for Health was a reward for loyal political service rather than an indication of interest in the provision of health services.113 Assuming John Lindell may have wished to change admission policy in the Geriatric Hospitals, he did not have a strong Minister to back him in the face of protest from the committees of management of these institutions. Individual members of these committees who were able to gain the attention of the Minister, or better, the Premier could ensure any measure they objected to was not pursued. exception. That is Lidcombe was, from the period around 1914, under a medical model of administration, not, as Mount Royal continued to be, a charitable model. In the period 1910-1914 a Labor government in New South Wales, unlike Victorian governments of any complexion, included health services in its policy platform. At the time this meant the direct provision of hospital services by the state alongside the large metropolitan voluntary hospitals. The changes introduced then were part of a general move to upgrade the facilities of asylums so they catered better for the needs of the chronically ill, G. Marcan & J. Ballard, A Historical Tour of Lidcombe Hospital, Torch Publishing Co, Bankstown, 1995, Dickey, 1967, op. cit. pp.541-555. 112 In a submission to the inquiry into Victoria’s hospital services in the early 1970s, the Geriatric Medical Officers Association noted the lack of medical representation in policy making areas such as committees of management of the institutions and the Association of Geriatric Centres, Personal papers Dr John Shepherd. 113 McCoppin, 1974, op. cit. p.95. McCoppin illustrates the point with the example of V. O. Dickie, Minister of Health from 1965 to 1970, who had not, before his appointment
153
The isolation of geriatricians within Victoria’s general hospital system was reinforced by a measure introduced by the Federal government, a measure that effectively sidelined any attempt to introduce specialist medical services for infirm old people. It was a measure that was very influential in the provision of hospital services in the states, but one that was introduced apparently without any reference to them. In an amendment to the Hospital Benefits Act (1951) that came into effect in early 1963, the federal government provided a subsidy for long-term care, thus entering a field that had formerly been the responsibility of the states. This provision derived from the operation of the system of voluntary hospital and medical insurance introduced by the Liberal-Country Party coalition government. From the inception of the Act in 1951, provisions were made for the payment of subsidies by the federal government to enable insurance funds to keep their rates at an affordable level while still providing cover for patients who needed frequent admission to hospital (public or private) for longstanding illnesses. Public hospitals also received a daily benefit for the care of uninsured patients. The association between advancing age and sickness or dependency ensured that old people were most prominent amongst the beneficiaries of these subsidies.114
The subsidy introduced in early 1963 was directed towards the needs of individuals who were not covered by hospital insurance and who were deemed to require long-term care (there was already a benefit in existence for those who were so covered).115 Like the other subsidies for hospital care, this benefit, calculated on a daily basis, was paid directly to the institution. As a consequence, a special category of hospital bed was designated – the nursing home bed – out of a motley collection of provisions for the long-term care of, in the main, dependent old people. They included the infirmary wards in the Geriatric Hospitals, those in the asked a single question or made any statement in the Legislative Council (the State Upper House) relating to health matters. 114 Kewley, op. cit. pp.353-358. The effect of the introduction of the nursing home subsidy in Victoria is documented in A. Howe, ‘Report of a Survey of Nursing Homes in Melbourne’, Working Paper no 10, National Research Institute of Gerontology and Geriatric Medicine, October, 1980, p.10-11. 115 Some insight into the system of benefits available then may be found in the parliamentary debate on this matter. Allan Fraser, MHR for Eden-Monaro, pointed out that patients already in ‘rest homes’ who had hospital insurance, received a benefit of one pound per day. If that patient then was admitted to a public hospital that institution, with
154 voluntary agency homes, and the privately owned convalescent, rest homes and small private hospitals scattered throughout the more affluent suburbs of the capital cities. To be eligible for the benefit a provider of long-term care had to be registered and formally recognised by the Commonwealth.116 At the end of 1968 a supplementary subsidy was introduced to pay for patients who were considered to need ‘intensive’ care; that is those who were substantially dependent on nursing care.117 Unlike all other subsidies for hospital care, eligibility for the nursing home subsidy did not require a medical assessment of those requesting admission. It was based on the unexamined view that the only possible response to old age infirmity was the provision of bedcare. It resulted in a proliferation of nursing home beds, many of them in Victoria in church and voluntary agency homes but also in the private sector, and the emergence of a powerful lobby group whose interests conflicted with the advocates of rehabilitative geriatric services.118
Conclusion The nursing home benefit did nothing to advance the cause of the geriatrician, nor did it diminish the use of custodial care for infirm old people. In Victoria (and indeed also in the other states) it undermined the tentative beginnings of the geriatric service by adding to the possibilities for discharging infirm old people from the public hospitals without using the services of the geriatrician. Hospital based medical staff were reinforced in their predilection for dismissing infirm old people from the field of active medical work, and the State government was relieved of some of the burden of funding long-term care. The nursing home subsidy also, incidentally, provided a source of funding for the Geriatric Hospitals all its facilities and trained staff, would receive 8 shillings per day, Australia, House of Representatives, 1962, Debates, vol HR37, p2791. 116 Private hospitals that provided care for the long-term sick as well as the acutely ill had to chose which type of service they would continue with because of the conditions attached to the subsidy. 117 This provision reinforced the tendency to accept that bed-care was the only response to infirmity and with a financial benefit involved, moves to introduce rehabilitation treatment which could minimise the need for care were unlikely. 118 In 1966 there were 23.4 beds per 1000 persons aged over 65 years, in 1976 there were 27.3 per 1000, an increase that was just ahead of the growth in aged population, Howe, 1980, op. cit. p19. In absolute numbers the total of beds available in State hospitals, private and church nursing homes rose from 6665 in 1963 to 8321 in 1970, p.11. See also, M. Coleman, ‘The Pattern of Permanent Care for the Aged’, Geriatrics Conference, 1969, Geriatrics Conference 1966-1976, op. cit. pp.47-57. Coleman notes that in Victoria at this time 71 per cent of nursing homes in private hands were managed by their proprietors, 30
155 in providing long–term care. The common perception in the Victorian community that the provision of custodial care was the most appropriate response to old age infirmity was reinforced financially, before the doctors developing geriatric services in the former custodial care institution had a chance to contest the practice. The nursing home emerged as the appropriate response to a generally perceived need, leaving the question of appropriate medical services for old people at risk of being consigned to the nursing home completely sidelined. The Hospitals and Charities Commission was helpless in the face of a process that undermined its efforts, ambiguous as they were, to rationalise provisions for long-term care and to provide treatment for a neglected group in the Victorian community.
Nonetheless, within the small circle of Geriatric Hospitals and the larger voluntary agency homes, geriatricians did exert an influence on the provision of long-term care by establishing standards of service provision and, to a limited extent, diminished the need for such care through the provision of rehabilitation treatment. In a survey of hospital services commissioned by the Victorian government in the early 1970s, it was noted that the Geriatric Hospitals ‘appear to have a good record with respect to rehabilitation and care of the elderly’. However the reservations that accompanied this observation highlight the limitations of the achievement of the doctors who persevered in developing the role of geriatrician. It was noted that the institutions were very large, and while size permitted economies of scale, it also produced an institutional and impersonal atmosphere that was far from ideal. Outside the institutions, however, this achievement paled into insignificance in comparison with the proliferation of custodial care provision in the community, on the basis of the nursing home subsidy.
In establishing a medical role defined in relation to old age, geriatricians had aligned themselves with the community ethos of doing ‘something’ for the deprived and infirm aged. In time they settled into a role defined by their committees of management on one hand, and by the total lack interest on the part of their medical colleagues on the other. Employed in
per cent were managed on behalf of financiers of some kind. She also included details of large financial enterprises that emerged at this time to provide nursing homes, p.53-54.
156 institutions closely associated with the Hospitals and Charities Commission, geriatricians in Victoria in 1970 may be fruitfully compared with the institutional psychiatrist in nineteenth-century Britain. There also the number of doctors employed increased and the institutions became more numerous. While the barracks system of hospital care in the Geriatrics Hospitals may have diminished, a similar atmosphere prevailed in which the principal medical career was that of medical superintendent. The geriatric medical officers who filled positions lower down the career ladder, had limited prospects, their role being confined to easing the burden on the superintendent.119
119 A. Scull, C. Mackenzie & N. Hervey, Masters of Bedlam, The Transformation of the Mad-Doctoring Trade, Princeton University Press, Princeton, New Jersey, 1996, p.269.
157 CHAPTER 4 PSYCHIATRY AND OLD AGE
Introduction In the early 1950s, Victoria’s mental health services were subject to an extensive process of reform under the direction of an English psychiatrist, E. C. Dax, who was appointed Chairman of the new Mental Hygiene Authority. The sort of geriatric service that John Lindell, Chairman of the Hospitals and Charities Commission, had tried to establish in the benevolent homes was also introduced into mental health services as part of this process. Although G.V. Davies, one of the few psychiatrists who were interested in health and illness in old age, showed in an early 1960s study that the patient for whom geriatric services were intended, was badly served within the existing organisation of hospital services, psychiatrists and geriatricians had to pursue their attempts to develop geriatric services separately because of the division between services related to physical illness and services related to mental illness. This chapter traces the development of a medical role in the provision of age-specific services in the mental hospitals. Themes prominent in the previous chapter emerge here also, the funding of hospital services and state/federal relations, and the relationship between the community and the medical profession in the provision of services. The difference is that the more advanced development of a theoretical model in relation to the geriatric service in the psychiatric system, makes it possible to examine the situation in Victoria up to the early 1970s, in relation to a body of sociological literature in which the claim is made that as psychiatry developed as a specialist field of practice, it became implicated in the maintenance of social order.
Within the psychiatric system the ‘geriatric service’ was one element in a broader process aimed at shifting the focus in treating mental illness, away from institutional provision into local, community-based mental health services. Psychiatrists were encouraged to develop an age-specific field of practice as part of a general development of the professional setting for psychiatry, a development that led to the revival of the role of public institution psychiatrist. Overall, by the early 1970s, they had not achieved this aim and their failure can be attributed to factors similar to those that
157 limited the development of geriatric services in general medical services. Factors such as the inability or unwillingness of the State government to provide adequate funding for the plans it encouraged its bureaucrats to implement, its reluctance to upset existing interests to facilitate these changes, and the effect of the subsidy provided by the Federal government for nursing home care.
There was, however another dimension to the failure of psychiatrists to establish either an age-specific form of hospital and medical service or a cognitive model for a psychiatry of old age, a dimension that was related to the professional environment in which they were situated. Local psychiatrists were in an ambiguous position because, first, although they were encouraged to develop a model of mental health and illness in old age, the biographical model that appeared to be most suited for this purpose was out of kilter with their colleagues’ preoccupation with a biological model of mental disease. Furthermore the overall shift away from institutional care that underpinned the development of psychiatric services in the 1950s and 1960s was limited in relation to elderly patients. The adverse circumstances in which these psychiatrists worked accounted largely for this failure. However, at the same time their limited achievements were also related to reluctance on the part of E.C. Dax to engage with the community-based groups who provided care for the infirm aged because he could not do so under the conditions he believed were necessary.
These ‘internal’ limitations on the development of age-specific psychiatric services offer some insights into aspects of the critical literature around the practice of psychiatry that began to appear in the 1970s. Theorists have sought, in different ways, to establish the claim that the emergence of psychiatry as an established specialty entailed collaboration between psychiatrists and dominant social forces with the effect that the operation of political power was extended into the realm of everyday life. The discipline of psychiatry became an instrument in the maintenance of social order by contributing, in the examples noted in this chapter, to the construction of femininity and the conditions necessary for a capitalist
158 economic order.1 There is no scope in this chapter for an extensive engagement with this literature but the early concern amongst Victorian psychiatrists with mental health in old age does provide some insights into the ‘disciplinary’ role of psychiatrists. They did engage in ‘problematising’ aspects of everyday life in relation to old age, but there were self-imposed limitations on the extent to which psychiatrists were prepared to be involved in dealing with this ‘problem’. These limitations were associated with the cognitive model psychiatrists sought to establish in the postwar period, and with their unwillingness to compromise their model of service, even at the cost of the continued neglect of infirm old people.
States of Confusion The psychiatrists who were interested in the care of elderly patients and the doctors in the Geriatric Hospitals were aware that they shared a common interest in focusing on elderly people who were at risk of needing custodial care. In the 1960s the only arena in which this common interest could be addressed was the annual Geriatrics Conferences sponsored by the Hospitals and Charities Commission, and, after 1965, the meetings of the Australian Association of Gerontology.2 The 1961 Geriatrics Conference was the first time this psychiatric dimension of the ‘geriatric patient’ appeared, at a session titled ‘Confusion – A Problem of Old Age’. A brief review of this session provides a useful introduction to the issues surrounding the efforts of psychiatrists to develop a specialist field of practice in the treatment of elderly patients during the 1960s.
The question of how the provision of medical services for the ‘geriatric’ patient was to be divided between psychiatrists and the nascent geriatricians in the Geriatric Hospitals had yet to be decided. While the medical practitioners involved in this work may have been able to
1 P. Miller, ‘Critical Sociologies of Madness’, in The Power of Psychiatry, P. Miller & N. Rose, eds, Polity Press, Cambridge, 1986, p.29ff. The texts referred to in this chapter are; J. J. Matthews, Good and Mad Women, The Historical Construction of Feminity in Twentieth-Century Australia, George Allen & Unwin, Sydney; A. Scull, Decarceration, Community Treatment and the Deviant – A Radical View, 2nd edn, Polity Press, Cambridge, 1984; N. Rose, Governing the Soul, The Shaping of the Private Self, Routledge, London, 1990. 2 For the Australian Association of Gerontology see Chapter Five.
159 negotiate an arrangement between them, a substantial obstacle lay in the administration of psychiatric services and physical illness services by separate, semi-autonomous bodies linked to the Department of Health. Another fundamental problem that faced psychiatrists, and geriatricians, was the question of how the approach to old people at risk of needing custodial care was to be shifted away from the provision of long-term care, towards episodic treatment supported by a range of welfare provisions. In Victoria the fragmentation of responsibility for the provision of community-based services, and the complete separation of such services from hospitals made the necessary coordination virtually impossible. In addition, doctors in the psychiatric service and the Geriatric Hospitals confronted a situation in which many individuals in the group of patients for which they were claiming responsibility did in fact need custodial care. To focus on the provision of acute hospital services in the face of this existing and unalterable demand was to run the risk of excluding these individuals from the medical sphere altogether - the only source of attention at this time for mentally disturbed old people.
The principal speaker in this Conference session was Lionel Cosin, the physician in charge of the Geriatric Unit at the Cowley Rd Hospital, Oxford, England.3 Earlier in the conference Cosin had described how his unit operated within a local hospital service, admitting all old people who were considered in need of hospitalisation and specialist medical services, including those patients whose mental state gave cause for concern.4 When Cosin referred to ‘all’ old people, he was referring to those who depended on publicly funded services. Anyone who could afford to pay for medical attendance, and chose to do so, would not be categorised in this manner. It was the unified approach to sickness in old people promoted by Cosin, that ensured the topic of mental disturbance was
3‘Confusion – A Problem of Old Age’, Geriatrics Conference, 1961, Geriatrics Conference 1956-1966, op. cit. pp.89-106. Cosin was one of the small group of English doctors who established the Geriatric Service to provide appropriate hospital and medical services for old people at risk of needing custodial care, see Chapters Two and Three. Cosin’s association with the efforts of Victorian doctors to establish similar services began early in the 1950s when John Lindell, visited England. It continued into the late 1970s when the Hospitals and Charities Commission brought him out to Victoria to advise on the development of a Geriatric Service in the eastern suburbs, see, Dr L.Z. Cosin, ‘Report on Eastern Suburbs of Melbourne Geriatric Services Development & Manvantara Hospital, June, 1979. 4 Ibid. p.20-21.
160 presented on this occasion as ‘confusion’.5 The term indicates the existence of a condition requiring investigation, with the possibility that it is treatable or at least manageable, by a physician or psychiatrist. The approach promoted during this conference session contrasted with the more common response that saw mental disturbance in the elderly as a form of insanity, an irremediable and hopeless condition which, until the category of voluntary admission was established in the State mental hospital, required certification as insane.6
The contributions to the discussion from a local geriatrician and a psychiatrist made it clear there were significant obstacles to overcome before they too could present the condition of mental disturbance as generic ‘confusion’. John Shepherd, recently appointed medical superintendent of Mount Royal Geriatric Hospital, made the point that while he was aware of the need for immediate and appropriate diagnosis of mental disturbance, and he believed he had the facilities to provide such a service, his lack of authority in regard to his institution’s admission policy limited the scope of his activities.7 The Hospital continued to admit patients according to position on a waiting list and it was impossible to provide the immediate attention these patients required. Shepherd’s remarks revealed the shortcomings of the services provided in the Geriatric Hospitals. He may also be interpreted as staking a claim to territory that belonged, in as much as it was anyone’s, to the psychiatrists. His comments foreshadow a dispute that was to arise in the future between geriatricians and psychiatrists.8
5 The term ‘mental disturbance’ will be used in this chapter to refer to conditions that brought elderly patients into the psychiatric service. Use of the term ‘confusion’ as recommended by Lionel Cosins, did not become common in Australia until the late 1970s and this chapter deals with the period from the mid to late 1950s, to the early 1970s. Anna Howe notes that the term ‘confusion’ did not enter everyday use until the late 1970s when psychogeriatrics was first included as a topic for discussion at the annual conference of the Australian Association for Gerontology, A.L. Howe, ‘From States of Confusion to a National Action Plan for Dementia care: The Development of Policies for Dementia Care in Australia’, International Journal of Geriatric Psychiatry, vol 12, 1997, p.166. Professor Tom Arie from Nottingham used the term ‘confused elderly’ at this meeting and it was taken up generally from there. Arie’s influence would have been reinforced when local psychiatrists were sent to his unit for postgraduate training in psycho-geriatrics in the early 1980s, when renewed efforts were made to develop psycho-geriatric services, Personal Communication from Assoc Prof. E. Chiu 27/9/2000. 6 See Chapter Two. 7 Geriatrics Conference, 1961, op. cit. p.97-98. For admission policy in the geriatric hospitals see Chapter Three. 8 An indication of the extent of the differences between ‘geriatricians’ and ‘psychogeriatricians’ may be found in the response of psychiatrists to the establishment of a psychogeriatric unit at Mount Royal. The unit was opened in the mid-1980s under the
161
The other local contribution to the session was made by E. C. Dax, Chairman of the Victorian Mental Health Authority and consultant psychiatrist. Dax chose to speak about an aspect of the problem presented by ‘confused’ old people, that was important because it highlighted a neglect that should have been easily rectified. It was, however, not one of the most pressing problems faced by the psychiatrists he encouraged to develop specialist medical services for elderly patients.9 Cunningham Dax was appointed Chairman of the newly constituted Mental Hygiene Authority in the early 1950s, with a commission to reform public mental health services in Victoria.10 It is not clear that the use of the term ‘hygiene’ by Victorian legislators indicated any special understanding of the scope of activity of the new authority as being concerned with the ‘art of healthy living’ as well as the treatment of disease. In any case hygiene was soon replaced, informally, in the title of the Authority by the word ‘health’. When he spoke at the Geriatrics Conference Dax was at the end of his first decade as Chairman and it was almost four years since he had instigated moves to establish special geriatric services within the mental health system.
Dax began by acknowledging that mental disturbance in some elderly patients was a sign of serious and, often, irremediable disease, soon followed by death. He chose, however, to emphasise the point that in many elderly patients mental disturbance was just as likely to be an indication of inappropriate medical care, as of the mental state of the patient. He gave the example of an elderly man he had been called to
direction of J. Tulloch, one of the first locally trained physician geriatricians. A memo to the Chairman of the Victorian Health Commission from the Directors of the Hospitals Division and Mental Health, calling for a formulation of policy guidelines relating to a rational development of services, notes that the proposal to establish the unit at Mount Royal was ‘not necessarily desirable’. This memo followed a meeting in 1979, between the medical administrators at the Geriatric Centres in the metropolitan area and the psychiatric hospitals, at which the recurring topic of co-ordination of services between the two sections of hospital services was discussed. VPRS 4523/P2/1064/1979-45. A personal communication from Dr Herbert Bower, psycho-geriatrician, 17/7/2000, suggests that the differences between psychiatrists and physician geriatricians in Victoria were resolved amicably during the 1980s. 9 Geriatrics Conference 1961, op. cit. p.89-91. 10 R. Inall, State Health Services in Victoria, Occasional Monograph No 4, Department of Government and Public Administration, University of Sydney, 1971, p64.ff; B. Robson, ‘An English Psychiatrist in Australia: Memories of Eric Cunningham Dax and the Victorian Mental Hygiene Authority, 1951-1969’, History of Psychiatry, 13, 2002, pp.69- 87.
162 assess because of the man’s response to admission to hospital for a procedure.
The man had refused to cooperate in what he viewed as an assault on his person, and the medical staff had interpreted his reaction as requiring a psychiatric opinion. Dax pointed out that the man’s response arose not so much from his own mental state, as from the approach taken by medical and nursing staff. They had failed to provide an explanation of the situation so he could understand it; had failed to take account of the possibility that the hyoscine they gave him might not have been appropriate, or that his history of heavy drinking may also affect his reaction to it. Confusion in this case was not so much related to the patient’s condition - he could have been ‘nursed’ through that, Dax said - as to failure on the part of medical and nursing staff to perceive his particular needs.11
Lionel Cosin amplified the point that confused thinking in old people did not necessarily indicate an irretrievable breakdown in an individual’s capacity to continue to live in the community. He referred to surveys of the area served by his hospital showing that many elderly people lived well and happily in familiar localities with the support of families and neighbours, despite some degree of mental confusion. It was only when a crisis fractured their social competence that their mental state became a matter for concern: a crisis that might arise from changes in physical condition, social situation or a combination of both. By focusing on these elements, through medical treatment and support in the domestic environment, the patient’s competence could be restored.12 But it was not only access to immediate hospital admission that made it possible to regard mental confusion in the elderly as a treatable condition. This group of elderly patients needed also to be lodged within a network of observation and support, extending from the geriatric unit into the domestic environment, and this included a promise by hospital authorities to carers that should it be necessary, immediate readmission would be available. Social and medical support was provided to reinforce, what
11 Geriatrics Conference, 1961, op. cit. p.89-91. 12 Ibid. p.92-94.
163 Cosin believed to be, the most important factor in maintaining competence in everyday life. That is ‘how one feels about one’s ability to cope’.13
Dr C.J. Cummins, Director General of the Department of Public Health in New South Wales and responsible for overseeing the State-run hospitals, proposed another ‘community’ view. He also advocated the provision of the appropriate acute facilities to ensure sick old people were properly investigated. At the same time he referred to the special provision necessary for those who were ‘completely out of touch with reality’, so that they could ‘exist in an atmosphere of tranquillity removed entirely from any conflicting influences with which (they) … find it hard to cope’. 14 Around the time of the conference, a Royal Commission into one of the large mental hospitals in New South Wales, had brought to light the appalling conditions in which old people were cared for there. Following the recommendations of the Commission, Cummins’ department had removed these patients en masse into unused district hospitals, that were then given over to the management of church groups.15 This move was certainly a matter of expediency – the removal of these patients was not associated with the provision of any special form of care at the time. Force of circumstances may have meant that in this case Cummins presided over a response to the needs of infirm old people that he knew was inadequate. At the same time, however, under his direction, steps were being taken to establish specific services in New South Wales, for old people at risk of needing custodial care, and these did include special medical services. Cummins’ acknowledgment that the provision of age- specific hospital services also needed to take account of the needs of those who required long-term care meant that it was more likely that appropriate provision would be made.16
13 Ibid. p.2-21. 14 Geriatrics Conference, 1961, p.96. 15 Following the Royal Commission a Division of Establishments was set up within the Department of Health, and separated into three sections of which Geriatrics was one. Under the first Director, Sidney Sax, this Division focused on development of community based services to minimise the need for institutionalisation. Cummins hoped to encourage church and other voluntary groups to provide the facilities for those old people who needed long-term care. Presumably this is what he referred to in his talk at the 1961 Geriatrics Conference, when he spoke about another ‘community view’, Personal communication from Dr S. Sax, 13/4/2000; ‘Care of the Aged and Chronically Ill’, Editorial, MJA, vol 2, 1960, p.587-588. 16 MJA, ibid.
164 The emphasis Cosins put on acute medical services raised the possibility that those patients whose needs could not be met in this fashion would be neglected.17
In view of the problems Cunningham Dax faced when he took on the task of reforming the State’s mental health services, it might have been expected that he, like Cummins, would have referred to the need to make suitable provision for old people whose immediate needs could only be met through the provision of long-term care. The extent of the difficulties in relation to elderly patients that confronted Dax when he first took on the position of Chairman of the Mental Hygiene Authority, was made very clear in a survey of the country’s mental hospitals in the mid-1950s.18 Alan Stoller another English psychiatrist who came to Australia in the late 1940s, was commissioned to undertake this project by Earle Page, then Commonwealth Minister for Health.19 In Victoria, Stoller found a situation that, he said, was roughly the same in all states: The problem of the senile has been a severe burden to all Mental Hygiene Departments, ... It is interesting to note that, although the number of seniles had increased from 1948-53, the proportion in the population had remained constant. Senile admissions were appreciably higher in 1951-52-53 than in 1947-48-49, and the
17 In fact the plight of old people in England who had nowhere else to go other than the publicly funded institutions, received much publicity in the early 1960s and this included those who were admitted to mental hospitals because there was, apparently, nowhere else for them, B. Robb, Sans everything, A Case to Answer, Nelson, London, 1967. Peter Townsend’s study published in 1962, found old people in local authority accommodation well below the standard of the public assistance infirmaries where they may have been accommodated before physicians such as Cosin and Marjory Warren established the more rigorous standards of illness that saw these people put back into the community, P. Townsend, The Last Refuge: A Survey of Residential Institutions and Homes for the Aged in England and Wales, Routledge & Kegan Paul, London, 1962, p.27ff, pp.34-36. Pat Thane notes that the effects of Geriatric Services were slow to spread amongst hospital services in general because the success of the Service depended upon the commitment of the person in charge of it, Thane, 2000, op. cit. pp.451-453; see also C. Webster, ‘The Elderly and the Early National Health Service’, in Life, Death and the Elderly, eds, M. Pelling & R.M. Smith, Routledge, London, 1991. 18 Report on Mental Health Facilities and Needs of Australia, presented to the Commonwealth Minister for Health, by A. Stoller with K. W. Arscott, 1955, pp.56-94. 19 Stoller was appointed Chief Clinical Officer in the Mental Hygiene Authority under Dax, but could not take up the position until 1955 because he was occupied with this survey.
165 proportion under care in mental hospitals was twice that of the proportion in the community. Roughly a third of all admissions were over the age of 60. Many of these were obviously sent in to die, as 40 per cent of the deaths which took place were within a year of admission.20
Psychiatrists not only had to deal with a rising number of admissions, they also had responsibility to provide proper care for patients who had been admitted when younger and grown old in the mental hospital.21 Many in this group no longer needed to be in a hospital environment, but there was nowhere else for them go. There had always been some exchange of patients between the psychiatric hospitals and the benevolent institutions (now Geriatric Hospitals) and this continued. However such patients also had to take their place in the queue for admission.
Why did Dax not join Cummins in calling for the proper provision of long–term care? The Geriatrics Conference was a suitable venue for highlighting the needs of a neglected group of old people because the conferences were attended by representatives of the church and voluntary groups that, from the 1950s when the Commonwealth began to provide subsidies for age-specific accommodation, had begun to establish an extensive field of activity in providing special forms of accommodation for the aged.
In choosing to follow Cosins and emphasise the provision of appropriate medical services in an acute setting, Dax was, no doubt, trying to avoid encouraging what he clearly believed to be a too-ready resort to the provision of institutional care in Victoria.22 In his view, institutional care
20 Stoller, 1955 op. cit. p.169. 21In his Beattie-Smith Lecture, J.F.J. Cade noted that the mental hospitals accepted patients unwanted anywhere else although they did not necessarily need psychiatric treatment, ‘Beattie-Smith Lecture’, MJA, vol 2, 1951, p.218. 22 E. C. Dax, ‘The Accommodation and Treatment for Mentally Disturbed Geriatric Patients’, in Growing Old, Problems of Old Age in the Australian Community, ed A. Stoller, F. W. Cheshire, Melbourne, 1960, pp.40-45, Second Australian Medical Congress, Plenary Session on “The Problems of the Aged in Society’, MJA, vol 2, 1965, p.565, and, ‘The Problem of the Aged in Society’, MJA, vol 2, 1966, pp.201-203. It is open to question whether the demand for institutional care arose from a general disinclination on the part of Australians to take care of their infirm old people at home. The doctors who had regular contact with families in this position were inclined to dispute this and many applicants for institutional care did not have families, A. Howe, ‘Family Support of the Aged: Some Evidence and Interpretation’, Australian Journal of Social Issues, vol 14, no 4, 1979, p.266. Richard Gibson, the physician who established a Geriatric Service at the
166 should be aligned with a system of acute services, such as those Cosins had described, to ensure that only those who needed long-term care were admitted to institutions. However in view of the lack of facilities for old people whose mental state had led to their rejection by family, neighbours and other institutions, it seems short sighted to emphasise the provision of acute services from which patients would be discharged.
Dax’s insistence that the provision of acute medical services should precede the provision of institutional care certainly reflected a response to the local situation in which the needs of infirm old people were interpreted wholly in terms of custodial care. It also reflected I believe, Dax’s objective in reforming the mental hospital system; that was to establish a system of acute medical services backed by rehabilitative facilities, underpinned by research based on a biological interpretation of mental disease.23 In a professional context shaped by this intellectual orientation the provision of age-specific psychiatric services was a means of dealing with that remnant of patients for whom this approach was unsuccessful. Psychiatrists were limited in what they could achieve in terms of a cognitive model to mental health in old age by the overall model governing the interpretation of mental disease, and were limited to establishing services to support patients for whom this model had nothing to offer. Their efforts to do this were dogged by the need to accommodate those old people who could not be returned to the community, a problem that was not confronted, partly because of Dax’s insistence on the priority of acute medical services. At the same time, while psychiatrists were encouraged to develop a psychiatry of old age, the uselessness of the biological model in this venture meant that doctors were not attracted to the field.
Royal Newcastle Hospital, said in 1970, that families were willing to care for their old people ‘and they will do so if presented with a properly assessed and secure proposition’, quoted in S. Sax, A Strife of Interests, Politics and Policies in Australian Health Services, George Allen & Unwin, Sydney, 1984, p.213. Herbert Bower, on the other hand, the Victorian psychiatrist who played a prominent part in laying the foundations for psycho- geriatrics, said in his Beattie-Smith Lecture in 1964, ‘The younger generation is quite prepared to go to considerable lengths in relief of intolerable living conditions experienced by the aged, but it must be on their terms, and must not involve them personally.’ MJA, vol 2, 1964, p.287. 23 B. Robson, ‘The Making of a Distinguished English Psychiatrist: Eric Cunningham Dax and the Mythology of Heroics’, PhD Thesis, University of Melbourne, 2000, p.137ff.
167 Bringing Old Age to Light in the Mental Hospitals The ‘severe burden’ of providing appropriate care for old people in the mental hospitals, highlighted by Stoller in his survey, was but one aspect of the complex task that confronted Cunningham Dax in the reform of the State’s mental health services. It was a task commissioned by a State government unwilling to give the first Director of the newly constituted Mental Health Authority control over the finances at his disposal and unwilling, possibly even unable, to match its demand for reform with the appropriate level of funding.24 When Dax spoke at the 1961 Geriatrics Conference he had already taken steps to develop special psychiatric services for all patients over the age of 65.25
Herbert Bower, medical superintendent of the Beechworth Mental Hospital was appointed medical superintendent of Willsmere Hospital at Kew, and the institution was given over almost entirely to the care of elderly patients.26 Bower, ‘young, ambitious and confident’, a newcomer himself to Australia, was one of Dax’s supporters amongst Victorian psychiatrists, not all of who approved of the approach he took to reforming the public mental health institutions.27 At Mont Park Hospital, G.V. Davies was allocated wards designated for the treatment of elderly
24 As early as 1952 the annual report of the new Mental Hygiene Authority noted the inadequacy of the funds available to it. This was compounded by the necessity for the Chairman of the Authority to receive authorisation for expenditure from the Public Works Board, a process that led to lengthy delays in executing plans for building and refurbishment. The problems Cunningham Dax faced arose from the administrative setting in which he had to work. The Mental Health Authority was one of the semi-autonomous bodies that oversaw the provision of the State’s infrastructure – power, roads, hospitals etc. In this administrative system ministerial control was exerted principally by control over finances, control separated from policy for which the head of the relevant authority was responsible, A. F. Davies, 1960, op. cit. pp.184-186. For the state of Victoria’s finances in the 1950s and 1960s, see Chapter Two. The Federal government had, since 1948, made some contribution to the States for the upkeep of patients and capital works in mental hospitals. Payment of the Age Pension for old people who were pensioners, ceased when they entered a mental hospital. In 1948 legislation was introduced to enable the payment by the Commonwealth to the States to cover the loss of revenue involved, and patients in State mental hospitals were not required to pay hospital fees. This situation continued until 1966 when amendments were introduced to ensure payment of the Age Pension continued following admission to a mental hospital in the same way that pensioners continued to receive payments during admission to a general hospital. Kewley, op. cit. p.249, p.305, pp.422-423. 25 Age of eligibility for the Age Pension had, since 1909, defined the starting point of old age in Australia and the category of the ‘elderly’. 26 E.C. Dax, Asylum to Community, The Development of the Mental Hygiene Service in Victoria, F.W. Cheshire, Melbourne, 1961, p.100ff. 27 Bower joined the Mental Health Department in 1949 as an emigrant from Europe and responded readily to Dax’s enthusiasm, Robson, op. cit. 2000, pp.38-40.
168 patients. Davies, a physician who took up psychiatry late in his career, exemplified the trend, noted by Humphrey Rolleston in the 1920s, whereby doctors most interested in the topic of illness in old age were those at that stage of life themselves.28 Davies believed the similarity in age between himself and his patients made for a degree of empathy not common in doctor-patient interactions.29 The prominence of just two psychiatrists, Davies and Bower, in this account of the early days of age- specific psychiatric services suggests that another problem Dax faced was a lack of interest on the part of other psychiatrists in this field of work.
There was little difference in the services geriatricians were commissioned to establish in the benevolent institutions in the late 1950s and those proposed for the psychiatric system. Both services were based on an English model in which hospital and community based services were combined in the objective of limiting the need for institutional care for elderly people. Had there been any possibility of cooperation between the Mental Health Authority and the Hospitals and Charities Commission (the body responsible for overseeing the provision of general hospital services), the one type of service would have served the interests of both authorities. There was, however, a significant difference between the two ventures, one that had the potential to promise a more favourable outcome in the psychiatric institutions. In the mental hospital system, the move to develop age-related services was part of an overarching model of medical service where curative, preventive and restorative services were combined. The internal coherence of the service model within which psychiatrists worked did not diminish the effects arising from the isolation of mental hospitals from general hospitals on one hand, and welfare provisions in the community on the other. Nevertheless psychiatrists did have an advantage in this respect that was not available to the doctors in the Geriatric Hospitals.30 There the introduction of geriatric services was isolated from the general organisation of medical services, and the incongruity of the socio-medical model underpinning them with the disease-based model that informed other forms of medical work highlighted this isolation.
28 H. Rolleston, Some Medical Aspects of Old Age, Macmillan and Co. Ltd. London, 1922, p.7. 29 G. V. Davies, ‘Family Structure and Family Attitudes of Elderly Mental Hospital Patients’, PhD Thesis, University of Melbourne, 1967, Introduction. 30 Dax, 1961, op. cit. p.100ff.
169
In his description of the ideal ward setting for the treatment of elderly patients, G. V. Davies echoes the requirements Graeme Larkins listed for the effective operation of the rehabilitation unit in the Geriatric Hospital.31 Davies noted that even an old ward could be made welcoming with pictures on the walls, flowers, music and television – a comment that indicated psychiatrists, like their colleagues in the Geriatric Hospitals, also had to make do with settings that were often far from salubrious. A cooperative atmosphere amongst the various health professionals working in the unit reinforced this welcome, making patients and families comfortable in the mental hospital environment, one that often aroused apprehension. Davies also echoes Larkins in emphasising the necessity of separating the treatment setting from the long-term wards to ensure patients took a positive view of their condition. The more ‘sombre’ picture of mental disorder in the long-term wards could be discouraging.32
A geriatric service was planned for the mental hospital at Kew, which, after Dax renamed it, was known as Willsmere Hospital. It was to include an admission unit, early treatment facilities, long-term care and a visiting psychiatric service to local old people’s homes.33 The first Day Hospital in the psychiatric service was opened there in 1965. Like the Day Hospitals established at the Geriatric Hospitals, this innovative outpatient service served a number of purposes, all aimed at limiting the need to admit patients to hospital or, if admitted, to keep them there for shorter periods of time. Patients whose condition improved with treatment could be monitored after discharge, as could others whose living conditions increased the risk of breaking down. Day Hospital care provided some respite during the day for the carers of for mentally disturbed old people living at home, thus deferring, or perhaps even avoiding the need for admission to long-term care. Attendance at the day hospital was also a means of bridging the gap between hospital and what could be an isolated existence in the community for discharged patients.34
31 G. Larkins, ‘Modern Methods of Rehabilitation’, Geriatrics Conference, 1956, p.24, Geriatrics Conference, op. cit. 32 Davies, ‘Clinical Advances in Geriatric Psychiatry’, MJA, vol 2, 1959, p.45. 33 Dax op. cit. pp.135-137; Robson, 2002, op. cit. p.78. 34 H. M. Bower, ‘The First Psychogeriatric Day-Centre in Victoria’, MJA, vol 1, 1965, pp.1047-1050.
170 The development of a geriatric service was the lesser aspect of the task that faced Herbert Bower when he took up his post at Willsmere in the mid-1950s. He faced the problem of providing a satisfactory level of general accommodation and treatment services in a building that had been completed in the late 1880s, condemned as unfit for patients just prior to the beginning of the Second World War, but remaining in use without any upkeep. In his survey, Stoller described its physical condition as so appalling that he wondered if the renovations then in progress were worthwhile since the process would be so lengthy and maintenance so costly. In light of the condition of the buildings, it is almost insignificant that they were also overcrowded.35 It was also the case that most of these people would remain the responsibility of the hospital because there was nowhere else for them to go. In their institutional setting and in the practical problems they faced, psychiatrists were in a similar position to the geriatricians in the benevolent institutions, although conditions at Willsmere Hospital were even worse. Bower described early efforts to examine patients, ‘There’s an enormous amount of noise going on and … no privacy. The patient is lying in a bed, the pillows… are black with dirt, the linen hasn’t been changed, the patient hasn’t had a bath … there wasn’t enough staff’. 36
Cunningham Dax included the professional development of psychiatrists in his reform of mental health services. A postgraduate Diploma in Psychiatry was already available at the University of Melbourne and in 1955 the Mental Health Research Institute was established.37 The Department of Psychiatry and the Institute were affiliated when the Cato Chair of Psychiatry was established in 1965. Despite its small staff and limited facilities in the early years, there was a commitment at the Institute to research in a number of fields: clinical, epidemiological, biological and sociological. Dax was ready to support his medical staff in developing
35 Stoller 1955, op. cit. p.65-66. By January 1958 the institution housed 1,126 patients, Annual Report Mental Hygiene Authority, 1957. 36 Robson, 2002, op. cit. p.37-38. 37 The founding of the Institute and its first twenty-five years of work are described in J. Krupinski, A. Mackenzie, R. Banchevska, eds. Psychiatric Research in Victoria, Mental Health Research Institute & Health Commission of Victoria, Special Publication No 9, Melbourne, 1981.
171 their special interests and encouraged them to acquire postgraduate qualification in these fields.38
The changes in institutional psychiatric practice in Victoria took place alongside developments in the professional organisation of psychiatrists. The Australian Society of Psychiatrists, founded in 1946, became a College in 1964. In 1967 a scientific journal, the Australian and New Zealand Journal of Psychiatry, replaced the newsletter produced by the Society since its inception, the Australian Psychiatric Bulletin. Access to a broader potential patient base was ensured when, in the late 1960s, an agreement was reached between the College, the Australian Medical Association and the federal government, on a common fee for psychiatric services within the national system of hospital and medical insurance.39 This last development meant that psychiatric treatment became available to that section of the population who could not afford to pay fees outright, but whose means were sufficient to prevent them being classified as public patients. Psychiatrists in private practice may have benefited most from this measure but, together with the slow acceptance of voluntary admission in the public institutions, it would have broadened the patient base for state hospital psychiatrists also. Under Dax’s leadership, the reorganisation of psychiatric services in the State led to the rejuvenation of the role of the public institution psychiatrist. For psychiatrists interested in the topic of mental health and illness in old age, the situation offered both advantages and disadvantages. Their professional environment was conducive to disciplinary development but their institutional setting was dominated by the necessity to manage large numbers of individuals unwanted anywhere else.
The Geriatrics Conferences, run by the Hospitals and Charities Commission to promote the education of a range of groups involved in providing ‘care for the aged’, were the principal arena for disseminating the professional knowledge and techniques developed by the medical practitioners in the Geriatric Hospitals. The psychiatrists in the state mental hospitals joined them there occasionally but this arena was
38 Dax, 1961, op. cit. p.31. 39 W. D. & H. L. Rubinstein, Menders of the Mind, A History of the Royal Australian & New Zealand College of Psychiatrists, 1946-1996, Oxford University Press, Australia, 1996, p20, p.48.
172 secondary to publication in a professional journal. G. V. Davies’ work can be traced through articles published in The Medical Journal of Australia in the years before the Journal of Psychiatry appeared. Davies was also able to use the new structure in the organisation of the mental hospitals and the links with a university department, to develop a research program for a PhD thesis on the topic of mental illness in old age.40 An indication of the difference in professional standing of the psychiatrists cultivating the field of mental health in old age, compared to the geriatricians in Victoria, is that Herbert Bower delivered the prestigious Beattie Smith lectures in 1963. This gave the topic of mental health and illness in old age an airing in circles to which the doctors in the geriatric hospitals could never aspire. The lectures, generally an annual event, were held in memory of one of Victoria’s early and prominent practitioners in the field of mental illness, Dr W. Beattie–Smith.41 Bower shared the distinction with colleagues notable in other fields of psychiatry, including J. F. J. Cade, who developed the drug lithium for use in treating mental illness.42
A Local Psychiatry of Old Age Psychiatrists and the doctors situated in the Geriatric Hospitals were able to draw upon the work of British physicians and psychiatrists in developing their role of providing age-related medical services. Psychiatrists, however, were in a better position because they had access to patients who were acutely ill, whereas their colleagues in the Geriatric Hospitals were limited to supervising the provision of restorative treatment for a small proportion of their patients and long-term care for the remainder. Both groups of doctors were in the same position of cultivating a field of medical practice in an area where medical interest was, on the whole, conspicuous by its absence. Despite the difficulties faced by Herbert Bower and G. V. Davies, the two psychiatrists disseminated imported knowledge and Davies in particular, established the beginnings of a local contribution to be added to the newly emerging body of knowledge in the psychiatry of old age produced by British psychiatrists.43
40 Davies, 1967, op. cit. 41 C. R. D. Brothers, Early Victorian Psychiatry, 1835-1905, nd, no publisher, p.176-77. 42 ‘Beattie Smith Lectures’, MJA, vol 2, 1951, pp.213-219 and pp.245-250. 43 Herbert Bower named Martin Roth and Felix Post as the most influential of the English psychiatrists in his work. In 1965 the former was Professor of Psychological Medicine at
173
In 1962, Herbert Bower spoke at the Geriatrics Conference on the topic of psychiatric disorders in the elderly. He expanded the more general discussion on mental confusion in the previous year by outlining the process of classification that underpinned the diagnostic process advocated by Drs Dax and Cosins.44 The first two categories of mentally disturbed old people he described had long been recognised by doctors. They were those old people whose disordered thinking, associated with organic disease of the brain, gradually and inexorably developed to the point where the individual in question did not know how old he or she was, where they lived or recognise their relatives. He classified this group of patients as the senile dementias associated with organic disease of the brain, caused in some cases by faulty circulation.45
Bower’s point in emphasising the importance of diagnosis was that although about half of the cases of dementia admitted to psychiatric hospitals died within two years of admission, the other half remained alive. In view of the impossibility of altering the condition there was little to offer other than long-term care. In these cases, however, Bower believed some improvement could be achieved through expert care. The provision of a stimulating environment slowed the rate of deterioration to the extent that ‘they may still be reasonably alert people’ who find
the University of Newcastle (UK) and Clinical Director, Psychiatry Unit, Newcastle General Hospital, and the latter, physician at Bethlem Royal and Maudsley Hospitals. Personal communication from Dr Bower, 17/7/2000. 44 H. M. Bower, ‘Psychiatric Disorders in the Elderly’, Geriatrics Conference, 1962, pp.90- 98, Geriatrics Conference, op. cit. 45 G. E. Berrios, ‘Dementia, Clinical Section’, R. Porter, ‘Dementia, Social Section, Part 1’, T. Kitwood, ‘Dementia, Social Section, Part 2’, in A History of Clinical Psychiatry, The Origin and History of Psychiatric Disorders, eds G. E. Berrios & R. Porter, Athlone Press, London, 1995. As was the case with many other conditions associated with old age, mental disturbance was also explored and classified by French physicians, beginning in mid nineteenth century. The use of the term dementia to describe mental disturbance in old age seems to have emerged as other forms of mental excitement (dementia) were classified in specific organic or functional terms, for example the establishment of a relationship between syphilis and General Paralysis of the Insane. The distinction made by Pick, Binswanger and Alzheimer, between dementia associated with cerebral arteriosclerosis, that arising from lobar atrophy and senile dementia was a further step in this process. Around the time Herbert Bower gave his lecture, despite the histological delineation of these processes ‘there was still no general agreement about the nature of the relationship between cerebral degeneration and dementia’. Dementia continued to be ‘one of those words, freely but loosely used, and difficult to define accurately in useful clinical terms’, ‘The Evolution of Geriatric Psychiatry’, a paper read at a meeting of the Scottish Society of the History of Medicine, Medical History, vol 16, no 2, 1972, pp.184-193.
174 something to enjoy in life and who were thereby easier to manage in hospital or at home.46
A remark by John Cade in the course of his Beattie-Smith lecture, that more was to be gained by investigating the changes in the brain associated with the dementing process, than classifying forms of dementia, suggests that Bower’s interest in classification may not have been shared by his colleagues. It did however, at least offer the possibility of ameliorating the effects of a condition that could not be altered, a response to the immediate need of patients as opposed to doing nothing. More important, Bower’s stance highlighted the focus on diagnosis characteristic of the specialist skills in treating elderly patients. The emphasis on diagnosis indicated openness to the possibility that conditions could be alleviated, even if only at the level of day to day management, thus discouraging any tendency to view the condition of elderly people as hopeless.47
In addition to classifying the dementias, other distinctions in mental disturbance could now be made and they were associated with the development of therapeutic techniques in both general medicine and in psychiatry. Confusion related to identifiable organic conditions would clear as treatment was given for the condition that precipitated it. Or, as E. C. Dax had gone into some detail to say at the 1961 Geriatrics Conference, the patient could be nursed through such an episode if medical and nursing staff paid sufficient attention to that person’s needs. The other major change was that depression was now recognised as the basis of change in
46 H. Bower, ‘Sensory Stimulation in the Treatment of Senile Dementia’, Report on the Third Annual Conference, Australian Association of Gerontology, MJA, vol 1, 1967, p.1057. 47 Cade, op. cit. and Bower, 1964, op. cit. p.327-8; see also H.M. Bower, ‘The Differential Diagnosis of Dementia’, MJA, vol 2, 1971, pp.623-626.
175 mental state in elderly people and this was also associated with the development of pharmaceutical, surgical and electrical treatments in the postwar period.48 A discerning medical practitioner prepared to investigate his elderly patients would find that, in a majority of them, the condition could be alleviated. Pharmaceutical therapy also alleviated the effects of disordered thinking, ‘the so-called late paraphrenias’, conditions in which otherwise quite normal elderly individuals suffer from delusions related to persecution or sexual conduct.49
In psychiatry, just as had happened in general medicine and surgery, advances in therapeutic techniques had the effect of bringing elderly patients, who might otherwise have joined the ranks of the infirm aged, back into the realm of everyday life in the community. G. V. Davies provided a summary of such developments in an article published in 1959. He noted, that at this point, towards the end of the first decade of the new era in the mental health services in Victoria, one third of all patients over sixty, admitted for the first time to mental hospitals, were eventually well enough to be discharged.50 He gave the example of a man of seventy, suffering from melancholia referred by a psychiatrist who had been satisfied to interpret his mental state as being related to the patient’s realisation that his life was drawing to a close. This man was admitted to Mont Park Hospital and discharged two months later, following a leucotomy, going off ‘enthusiastically’ to ‘embark on a new avenue of work’. Davies suggests he may have been an exception in being treated in this fashion, leucotomy being resorted to only in selective cases that did not respond to electroconvulsive therapy or pharmaceutical agents.51 Not all problems of mental disturbance were so resolutely dealt with. Families often had to continue to care for relatives whose condition posed substantial difficulties despite the more optimistic medical approach to
48 A distinction between depression or melancholy, and dementia had been made much earlier. Kraepelin for example disputed that depression was an invariable symptom of dementia and that it inevitably degenerated into dementia, R. Porter, op. cit. p.60. The development of pharmaceutical treatments for depression made the distinction more telling. 49 Bower, op. cit. p.90-93. 50 (G) V. Davies, ‘Clinical Advances in Geriatric Psychiatry’, MJA, vol 2, 1959, p.43-46. 51 Davies, ibid. p.45-46. In a talk given at a seminar organised by the Victorian Council for Mental Hygiene, Cunningham Dax expressed the opinion that more attention should be given to the use of leucotomy in cases of depression in old people ‘because often enough their time is running out and they can’t afford to have a long illness at this age.’ E. C. Dax, ‘The Accommodation and Treatment for Mentally Disturbed Geriatric Patients’, in Growing Old, ed A. Stoller, F. W. Cheshire, Melbourne, 1960, p.44.
176 these patients. Davies hints at this when he writes that the news that admission of an old person to a mental hospital was just as likely to be followed by discharge, ‘ … cheers up some (relatives) and lets others know that, even if they thought so, their responsibility is not at an end.’52
Framing Old Age Davies, in common with British geriatricians in the early 1960s, identified the characteristic patient as female.53 At Mont Park Hospital, the number of females admitted in the early 1960s was two and a half times the number of men.54 Women between the ages of 70 and 80 were more numerous in this group than those in their sixties or over 90. Those who were widowed were more numerous than the married or single.55 In an earlier paper Davies noted that the typical elderly patient had lived through hard times. The depression of the 1890s may have caused hardship for their parents, blighting their childhood. In the 1930s Depression they themselves suffered similar hardship, perhaps compounded by the loss of husbands, brothers or sons in either of the two world wars. In the post-war period when prosperity brought good times for younger generations, these elderly women (and men too) often found themselves excluded by inadequate pensions or inflation eroded savings. Accumulated hardships, diminishing strength and perhaps sensory loss, made the changes brought by ageing intolerable.
52 Davies, 1959, op. cit. p.45. 53 J. Agate, The Practice of Geriatrics, William Heinemann Medical Books, Ltd, London, 1963, p.6-8. 54 G. V. Davies, ‘Female Geriatric Admissions to a Mental Hospital’, MJA, vol 2, 1965, p.309. 55 Davies points out that the preponderance of widows amongst mental hospital patients in Victoria contrasted to the situation in England where 54% of admissions of women over the age of 60 to mental hospitals were women who had never married. He wondered if ‘The Australian spinster … who over the last generation has so often carved out a rewarding career for herself and achieved a sturdy independence, may have a few secrets of successful aging that would help us all’, p.310. The overall preponderance of women over the age of sixty in the psychiatric hospitals arose partly from the admission of greater numbers of women than men in this age group, but also because of the women admitted when younger and grown old in the institution. G. V. Davies, ‘The Geriatric Population of a Mental Hospital’, MJA, vol 1, 1965, p.182. In his social history of medicine and madness in New South Wales between 1880 and 1940, Stephen Garton notes that by the 1930s patients admitted to the State Mental Hospital were more likely to be female and older than those admitted in the 1880s. However he also notes that although the proportion of married women amongst female patients was slightly higher than single women, there was no sharp differences in the rate of committal between these two groups and this situation did not alter greatly between 1880 and 1940, S. Garton, Medicine and Madness: A Social History of Insanity in New South Wales, 1880-1940, New South Wales University Press, Kensington, NSW, Australia, 1988, p.104 and p.147.
177 Women, Davies concluded, ‘having more restricted interests'’ were also more ‘emotionally affected by non-cerebral illnesses’ than men.56 They were, however, less likely to be affected by a life-time of heavy drinking, a working class male response to the difficulties they faced in life.57 Men, who may have had the stamina to withstand the effects of alcohol on their bodies while they were younger, finally subsided into mental breakdown when senescence weakened their capacity to deal with the effect of long- term intoxication.58 In keeping with his linkage between mental health in old age and social conditions, Davies also noted in a later paper that using the age of 60 to designate the onset of old age in women was no longer appropriate in postwar society. In contrast to their sisters in earlier generations, 60-year-old women in the 1960s lived longer than their male counterparts and, ‘with wider interests, cosmetics and hair tints, look and feel younger.’59
There may have been other factors in addition to lifelong hardship, underlying the restricted interests Davies noted in his elderly patients. The experience of John Lack’s mother suggests as much although she was not as old as Davies’ patients.60 Just as she reached the point in her life where she could see something for all her hard work in rearing four sons and keeping up a home for them and her husband in the working-class suburb of Footscray, she had what the family referred to as a ‘nervous breakdown’. Certainly her interests may have been restricted. She’d had to take all responsibility for three sons and another on the way, when her husband enlisted for war service. When he returned his ‘one day at a time’ attitude, a natural element in his character reinforced by his experience as a prisoner of war, exasperated her because she was inclined to save and to
56 Davies, 1959, op. cit. p.43. 57 The association between excessive consumption of alcohol and mental disturbance is a recurrent theme in Garton’s chapter on the topic of madness and men. Garton, 1988, op. cit. Chapter 6. 58 Davies, 1959, op. cit. p.43. The characterisation of the effects of a difficult life on women in terms of their constitution as females, and in men in terms of what was just beginning to be described as a disease (alcoholism) was, even when it was made not accepted uncritically by psychiatrists. J.F.J. Cade found that combining total admission rates of depressed women and alcoholic women on one hand, and those of depressed men and alcoholic men on the other, showed that male and female admissions were of the same order of magnitude, Krupinski, Mackenzie, Banchevska, 1981, op. cit, p.82. 59 G. V. Davies, MJA, 1965, op. cit, p.309-310. 60 J. Lack, ‘Melbourne: In and Out of My Class’, in ‘The Forgotten Fifties’, a special edition of Australian Historical Studies, vol 28, no 109, 1997, pp.159-164. Mrs Lack was somewhat younger than the patients Davies describes, nonetheless her case does serve to illustrate the multiple dimensions of the condition he describes as ‘restricted interests.’
178 plan. Paradoxically, he had been strengthened by his experience in war but the family had ‘been drained by four years of separation and anxiety’. When she had the opportunity and wished to go out to work, he forbade her, thus eliminating any outlet for her obvious capacity to manage life and in a sense putting to nought her achievements during his years of absence. Although he was an affectionate father and husband, and his actions were most likely prompted by the desire to spare his wife extra work, his misguided concern for her well-being contributed to a situation that, in time, sapped her vitality.
Davies’ characterisation of the ‘geriatric’ patient as the ‘feeble’ old woman exemplifies the gendered psychiatric diagnoses Jill Julius Matthews identified in her study twenty years later.61 Davies’ description of the condition of the typical patient in terms of her ‘restricted interests’ and ‘emotional response to non-cerebral illness’ seems to anticipate the judgements about womanhood masquerading as psychiatric diagnoses, that Matthews found in her study of women admitted to a South Australian mental hospital. Matthews concludes that to maintain any degree of mental equilibrium, women, in addition to coping with the vicissitudes of everyday life, have the added burden of negotiating the ‘maze’ of feminine existence. The goal in this process, of being a ‘good woman’, is one that is fundamentally unachievable and it is in finding a way to live with ‘failure’ that women face a double burden in maintaining a satisfactory degree of well-being. Mrs Lack’s case illustrates the combined obstacles posed by gender, class, and the anxieties of daily life in time of war.62 It may be, however, that the experience of the Depression marked elderly women in ways that over-rode influences relating to gender. The comments of women who reflected on their lives in Janet McCalman’s study of life in working-class Richmond, some of whom could have been contemporaries of Davies’ patients, with similar life experiences, suggest that the Depression marked their lives indelibly.63 These women also mention the obstacles they confronted as women. However such
61 J. J. Matthews, Good and Mad Women in Twentieth Century Australia, 3rd ed, George Allen & Unwin, North Sydney, NSW, 1987. 62 Ibid. p.200-201. 63 McCalman, 1984, op. cit. Chapter10.
179 difficulties pall besides the affront to their emotional security they experienced in the realisation that respectability was not the bulwark against ‘destitution and disgrace’ that many of them had grown up to believe. No doubt men were also shaken by this realisation, but for women, who overall had less power in the organisation of social life, and, as a consequence, may have put greater reliance on social forms, respectability could provide an emotional defence on the passage through the ‘maze’ of feminine existence. The loss of trust in life manifested by many survivors of the Depression, including Davies’ patients, was fundamental to their experience of growing old. The mental dis-ease Davies diagnosed in his patients in the 1960s, was related it seems, not simply to their experience as women but also to general social and economic conditions. They may have been, in Matthews words, ‘survivors of ‘a bygone generation’ without the status of mother, economically dependent on the government instead of a husband and often living in poverty, with ‘(their) only feminine function being occasional babysitter to … grandchildren’.64 However, for many elderly women poverty may have been life-long, and a government pension may have provided a degree of security not previously experienced. What made it difficult for them to share the exuberance of postwar prosperity was their loss of trust in life itself, a loss that blighted the remainder of their lives, and their relations with children and grandchildren.65
Herbert Bower joined Davies in emphasising the part played in mental disease by factors well outside the psychiatrist’s purview. Paradoxically, while a reductionist approach to understanding disease made the identification of depression in elderly patients such a worthwhile process, and the distinction between organic and psychogenic mental changes made for theoretical clarity, as Bower pointed out, it was, nonetheless, an artificial distinction because: Anatomical changes can never completely explain the symptoms of the senile psychoses; personal and environmental factors contribute towards the patient’s ability to withstand the cerebral insult … In
64 Matthews, op. cit. p.195. 65 Ibid. p.293.
180 short, any psychiatric illness must be regarded as one link in the causal chain of an individual’s life experience.66
In this situation a biographical approach to diagnosis was necessary, geriatric psychiatry being often concerned with sickness where ‘emotional stress and psychological mechanisms have fired off a mental disorder which has bodily repercussions.’ It was also necessary for the development of preventive health measures. G. V. Davies, in what may well have been the first local identification of the condition, notes that geriatric psychiatry required contributions from psychology, sociology and economics to fully comprehend the disorder of ‘unsuccessful ageing’.67 The dimensions of this project were foreshadowed in Marjory Warren’s conclusion to her outline of the ‘untreated case’ of old age infirmity, when she described those ‘… human forms who are not only heavy nursing cases in the ward and a drag on society but also are no pleasure to themselves and a source of acute distress to their friends.68 However, while these psychiatrists were ready to play a part in ‘problematising’ old age, it was by no means clear that they were also going to be involved in ‘disciplining’ old age.
Herbert Bower proposed a standard of normal senescence by which success or failure in the project of ageing could be measured, ‘mental and physical changes, normal for the age period, providing the essential prerequisites for good adjustment’.69 During the session on the medical care of the aged at the Australasian Medical Congress in Melbourne in 1952, A. T. Edwards, a psychiatrist from Sydney, listed some of the adjustments that may be required of the elderly adult. They included getting along with the spouse, adjusting to loss of employment and reduced income, living with physical infirmity, and finding satisfactory accommodation.70 The problem of establishing a norm of adjustment had been illustrated in J. S. Sheldon’s survey of a random sample of elderly
66 H. Bower, ‘Old Age in Western Society, Lecture 2, Psychiatric Aspects’, MJA, vol 2, 1964, p.328. 67 Davies, 1961, op. cit. p.153. 68 Warren, 1946, op. cit. p.841-842. Warren’s description displays a characteristic Haber notes is common to many advocates of geriatric medicine from Nascher onwards. While promoting attention to this neglected group, they also tended to emphasise the unpleasantness of decrepit old age, Haber, 1986, op. cit. p.67. The use of the term ‘unsuccessful’ in relation to old age decrepitude by Davies seems to continue the tradition. 69 Bower, 1964, op. cit. p.328. 70 ‘The Medical Care of the Aged’, MJA, vol 2, 1952, p.491.
181 people in the English city of Wolverhampton.71 As he went about interviewing people in their homes, he was constantly perplexed as to how to classify individuals along a scale of normal, normal plus and sub- normal because of the range of variability he noted. He found individuals who maintained an active life, contributing to the life of their community or family, despite significant physical handicaps and clearly identifiable disease conditions. Others, apparently free of such restrictions, had responded to the changes in their lives in old age by withdrawing from social interaction. For Sheldon, the people he surveyed illustrated the statement made by J. S. Ryle, the advocate of social medicine, that there was no normal versus abnormal in states of health but only a range of variability related to environmental conditions.72
The attempt to establish a norm of old age was a very different matter from establishing physiological norms in laboratories isolated from the ambiguities of everyday life.73 In contrast to the demonstrable differences of quantity that underlay definitions of organic disease, the norm of adjustment in old age, (if Dr Edward’s list is any guide) tends to reflect what may be required for the maintenance of social order. Wealthy old people were not required to deal with these matters while they had the resources to shield them from public scrutiny. Even living with physical infirmity was a very different matter for those with sufficient resources.74 Elizabeth Hunter, the central character of Patrick White’s Eye of the Storm, continued to rule the lives of her adult children and hired help as she subsided into decrepitude. She had the financial resources, which her children were not brave enough to alienate, to sustain her accustomed manner of living to the end and to pay for a housekeeper and private nurses. One of these nurses, Elizabeth took comfort from knowing, was able to perceive that ‘the splinters of mind make a whole piece’, and to
71 Sheldon, op. cit, p21, pp.86-180. 72 ‘For Ryle, biological normality was the quantifiable range of physiological variability which resulted from adaptation necessary for survival in a given environment’, Porter, 1993, op. cit. p.253. 73 Canguilhem, 1989, op. cit. p.35ff. 74 After she left Cheltenham Old People’s Home Fleur Finnie was employed to care for an elderly man who had suffered a stroke, at home. Finnie, and another untrained nurse, attended to this man’s every need, providing 24 hour attention, and his daily routine was a stark contrast to that of the old men in her first ward, Finnie, op. cit. p.39-40.
182 sustain her in her journey towards the realisation that she was but ‘a detail of the greater splintering’.75
The disorder inherent in increasing numbers of infirm old people requiring publicly funded care may not have constituted a threat to public order of the same magnitude as the adolescent delinquents who were the subject of psychological investigations into the experience of childhood in the 1930s.76 Nevertheless, although psychiatrists in Victoria did join other professionals in publicising the ‘problem of old age’, on the whole, local formulations of the problem lurking in the future of the western democracies – the relentless increase in numbers of dependent old people – emphasised managing the financial resources of the state, not the conduct of elderly individuals.77 The overall lack of interest amongst psychiatrists, in the problems of mental health in old age, and indeed amongst doctors in general, combined with the continuing emphasis on the provision of custodial care by community-based groups, meant that any disciplinary potential in Davies’ contribution to framing old age remained unrealised. As was the case in general medicine, psychiatry did become more involved in problems of mental disease in old age, but only in so far as elderly people were treated in the same manner as other adults. The response on the part of the knowledge makers in the Victorian psychiatric community, to the possibility of establishing a body of knowledge based on the social medicine approach to interpreting ill-health, suggests that it may also be the case that the fundamental interest in a reductionist model of mental health limited the possibilities for intervention by psychiatrists into the social world inhabited by ageing Victorians.
The emphasis Bower and Davies laid on a biographical approach to mental illness was not altogether at odds with trends in mainstream psychiatric research in Victoria in the 1960s. Soon after the Mental Health Research Institute was formally opened in May 1956, it gained recognition for epidemiological and social research, an area of study that was promoted by Alan Stoller, Chief Clinical Officer in the Mental Health Authority.
75 P. White, The Eye of the Storm, Penguin Books, Middlesex, England, 1982, p.89-90. 76 N. Rose, Governing the Soul, The Shaping of the Private Self, Routledge, London, 1989, p.121ff. 77 Current Affairs Bulletin, vol 5, no 8, 1950; N.G. Francis, ‘A Problem that Grows with the Years’, The Australian Quarterly, vol xxxvi, no 2, pp.50-56.
183 This reputation was reinforced in 1960, following the appointment of Dr Jerzy Krupinski, who described himself as ‘a medical administrator with a special interest in epidemiology and social medicine’.78 The commitment of researchers to investigating social influences on mental disorders would appear to have provided an ideal environment for studies similar to that conducted by Sheldon and, no doubt, others more sophisticated because of the range of statistical skills that were available.79 The emphasis on statistical methods and the appointment of a social worker early in the life of the Institute – Stoller’s interpretation of ‘sociological input’, one shared by Ian Wood at the Clinical Research Unit located at the Royal Melbourne Hospital - suggests that John Ryle’s model of social medicine influenced the approach to developing a research program in mental health.80
In the late sixties and early seventies, three social surveys were carried out within the Victorian community in country Heyfield, inner suburban Prahran and the north-west region of Melbourne.81 These opened up the possibility of establishing a focus on old age in the psychiatric field as Eric Saint had attempted to do in general medicine in his work, in the 1950s, at the Clinical Research Unit at the Royal Melbourne Hospital and Walter and Eliza Hall Institute.82 However, although older adults were included in these surveys there was no specific focus on them as a group. Research listed under the heading ‘epidemiology and social psychiatry’ in the history of the Institute suggests that the interests of researchers simply did not lie in this direction. Instead they were shaped by the most prominent features of the Victorian population at the time, that is growing numbers of adolescents and younger adults, the effects of an increased birthrate in the postwar period and high levels of immigration.83
78 Krupinski, Mackenzie, Banchevska, 1981. op. cit. Introduction. For ‘social medicine’ see Chapter Two. 79 A. Westmore, ‘Mind, Mania and Science: Psychiatry and the Culture of Experiment in Mid-Twentieth Century Victoria’, PhD Thesis, University of Melbourne, 2002, p.186. 80 See Chapter Two. 81 J. Krupinski, A. Stoller, A. G. Baikie, J. E. Graves, A Community Health Survey of the Rural Town of Heyfield, Victoria, Australia, Mental Health Authority, Special Publications, No 1, Melbourne, 1970 and J. Krupinski & A. Stoller, eds, The Health of a Metropolis, Findings of the Melbourne Metropolitan Health and Social Survey, Heinemann Educational Australia, South Yarra, Victoria, 1971, J. Krupinski, & A. Mackenzie, The Health and Social Survey of the North-West Region of Melbourne, Special Publication No 7, Mental Health Division, Health Commission of Victoria, Melbourne, 1979; Porter, 1992, op. cit, p.145-146. 82 Saint, MJA, 1953, op. cit; MJA, 1955, op. cit. p.161-165. 83 J. Krupinski, ‘Epidemiology and Social Psychiatric Research’ in Krupinski, Mackenzie, Banchevska, 1981, op. cit. p.17ff.
184 The numbers of people categorised as old – that is of pensionable age – had also increased, but as a group, the elderly, remained a small proportion of the whole population.84 It was left to G. V. Davies, who in 1969 was a Research Fellow in the Department of Psychiatry, to investigate the socio- psychological elements in senile dementia in different groups of elderly hospital patients.85
Neglect of the topic of ‘ageing’ in the Institute’s research during the 1960s is difficult to reconcile with Alan Stoller’s call, in the late 1950s, for research to develop the preventive measures necessary to ensure ‘successful ageing’. Stoller was a prominent participant in a two-day seminar on old age in Melbourne in 1958. The seminar was organised by the Victorian Council for Mental Hygiene and it brought together the small number of ‘experts’ on ageing in the Victorian community with the intention of promoting the prevention of ill health and maladjustment through education.86 The Council, consisting of both lay members and mental health professionals, including psychiatrists, was first formed in the 1930s as part of a world-wide mental hygiene movement that began, early in the twentieth century in the United States. It was one of a number of state-based Councils in Australia. In the 1930s the Council promoted the same type of project in relation to childhood and adolescence that it was
84 While there appears to have been no association between increasing numbers of adults classified as ‘old’ in the Australian population and the growth of a psychiatry of old age, there was also no association between rising numbers of children and child psychiatry. This speciality attracted only between five and ten per cent of psychiatrists in the late 1970s, M. Lewis, Managing Madness: Psychiatry and Society in Australia, 1788-1980, Australian Government Publishing Service, Canberra, 1988, p.139. 85 G. V. Davies, B Teltscher, & B. Davies, ‘Senile and Arteriosclerotic Dementia – a Study of Personal, Social and Family Data’, Australian and New Zealand Journal of Psychiatry, vol 3, 1969, pp.398-400. 86 The proceedings at this seminar were later published as, Growing Old, Problems of Old Age in the Australian Community, ed, A. Stoller, F.W. Cheshire, Melbourne, 1960. The list of participants included psychiatrists, E. C. Dax, G. V. Davies, and A. Stoller (Herbert Bower had only just taken up his position as medical superintendent at Willsmere Hospital); the first doctors appointed as geriatricians at Mount Royal, G. Larkins and R. Butterworth; Elizabeth Johnson, nurse and first officer in the Geriatrics Division of the Hospitals and Charities Commission, R. I. Downing, Ritchie Professor of Economics at the University of Melbourne who had recently taken on the project of investigating the means of restructuring the Age Pension to address the poverty experienced by some pensioners ; I. K. Waterhouse, lecturer in the Department of Psychology at the University; representatives of the Trades Hall Council, the Over 50s Association, the Old People’s Welfare Council and the voluntary agencies.
185 now promoting in relation to the ‘problem of old age’.87 However, the interest in old age was short-lived. Following publication of the proceedings of the seminar, the Council moved to other ‘social problems’ such as child abuse, drug and alcohol abuse, and suicide.88 In Stoller’s conclusion to the seminar he noted the importance of the early detection of mental ill-health in elderly people, calling for research into the multiple factors involved in ‘mental breakdown’. Interestingly, he did not refer to the possibility of this research occurring at the Mental Health Institute but called upon Victorian universities to cultivate research in the social sciences.89
In the early 1970s, although Stoller and Krupinski had ‘wrested significant initiative in mental health research away from the biologically-oriented groups within the mental hospitals and the university’, population studies at the Institute were abandoned.90 Researchers concluded that, in general, while health and disease ‘are the result of continuous interaction with the environment’, the problems of separating physical and psychological components limited the usefulness of examining them in their social environment. ‘Hard’ social data, they concluded, were less useful in understanding mental illness than they had previously thought.91 This truncated attempt to establish the discipline of social medicine in relation to mental health cannot be attributed to the limited development of social research in Victoria at the time.92 Rather, the conclusion that ‘hard’ social
87 Lewis, op. cit. pp.135-139. The Victorian Council played an active part in supporting the foundation of the first Chair of Psychiatry at the University of Melbourne by contributing funds for the purpose. 88 Ibid, p.140. 89 Stoller, 1960, op. cit. p.198. 90 Westmore, op. cit. p.189. 91 Krupinski, Mackenzie, Banchevska, 1981, op. cit. p.26. 92 The establishment of the discipline of economics at the University of Melbourne, under the direction of L.F. Giblin, first Ritchie Professor of Economics, led to the development of statistical skills and social surveys similar to those pioneered in England by Charles Booth. This disciplinary formation brought together a moral imperative to achieve a just distribution of resources and increasing technical skill, N. Brown, Richard Downing, Economics, Advocacy and Social Reform in Australia, Melbourne University Press, Carlton South, Victoria, 2001, pp.45-48. In the Department of Psychology at the University of Melbourne, under the leadership of O.A. Oeser, Professor of Psychology, social surveys were undertaken to ‘assess the interaction between ‘social structure and personality’ in rural and urban Australia’, N. Brown, Governing Prosperity, Cambridge University Press, Cambridge, 1995, p.194-195. These surveys were published in two volumes, Social Structure and Personality in a City, and Social Structure and Personality in a Rural Community, Department of Psychology, University of Melbourne, 1949-1950. Economics did contribute to the discussion of the ‘problem’ of old age in the 1950s through a study of pension rates, see Brown, 2001, op. cit. p.185ff, but there was, it appears no interest in old age in the Department of Psychology, Brown, 1995, op. cit. p194-195. In the Department
186 data was not so useful in understanding mental illness suggests a somewhat narrow understanding of what was entailed in such research. The limitations of the conception of the ‘social’ at the Institute, can be seen in the appointment of a social worker as a means of including the ‘social’ element in research, and the failure to attempt its development as a specific form of research expertise.
In following the model set by Ryle in the Oxford Institute, the founders of the Mental Health Research Institute thus also imported the deficiencies of this model in its conception of the ‘social’. George Rosen noted this aspect of British efforts to establish the discipline of social medicine in the 1940s and 1950s. Ann Oakley reinforces the point in her essay on the relationship between the work of Richard Titmuss, statistician turned ‘sociographer’, and the wider project of social medicine in Britain in this period. Oakley characterises it as a failure to ‘theorize and practise the study of the social relations of health as an activity which does not in some direct or indirect way feed off that of medicine itself’.93
A paper read by Cunningham Dax at the Second Australian Medical Congress in Perth in 1965 exemplifies the point made by Rosen and Oakley.94 Dax began by noting the need for ‘modifications in our society’ to diminish the difficulties experienced by elderly people, difficulties that played a part in the increasing incidence of mental disorder amongst this group. Following an examination of three problem areas, he concluded by
of Social Studies, although social workers began to extend their expertise into care of the aged in the 1950s, there was, it seems, no interest in developing a body of theory about life in old age. This may have been part of the general lack of interest in developing a critical tradition in the Department noted by R.J. Lawrence, author of the first history of the Australian social work profession, Laurence, op. cit. pp.205-208. Even a decade after Laurence made these comments, the situation had, it appears, not changed, B. Healy, ‘Social Work Research: Emergent Methods and Models for the Evaluation of Everyday Casework Practice’, in Social Work in Australia, Responses to a Changing Context, eds P.J. Boas & J. Crawley, Australia International Press and Publications Pty. Ltd, p.172. The survey conducted by Bertram Hutchinson with the assistance of the Department of Social Studies at the University of Melbourne, and published under the title, Old Age in a Modern Australian Community, in 1954 was a lone example of an investigation in which the experience of ageing adults was linked to their social status. However, it was instigated, not by academic researchers, but by charitably minded citizens, members of the Rotary Club of Melbourne. Hutchinson’s survey was later criticised by M. J. Jones, as lacking in systematic empirical material, M.A. Jones, The Australian Welfare State, Growth, Crisis and Change, George Allen & Unwin, Sydney, 1983, p.57. Jones was also critical of the methodology of the statistical surveys of the 1960s which identified poverty amongst old people, p.58. 93 Rosen, 1974, op. cit, pp.110-111; A. Oakley, ‘Making Medicine Social: The Case of the Two Dogs with Bent Legs’ in Porter, 1997, op. cit. pp. 92-94. 94 E. C. Dax, ‘The Problem of the Aged in Society’, MJA, vol 2, 1966, pp.201-203.
187 noting the interdependence of physical, mental and social aspects of ageing and that the integration of the three was vital to the maintenance of good health.95 In his view the ‘social component’ was the ‘weakest’ and to rectify this he advocated an Australia-wide survey of old people in institutions to identify what needed to be done to ‘get them out again, in to a community better organized and subsidized to receive them’.96 He illustrated the type of survey he had in mind by citing the few local surveys that were done in the 1960s. In Melbourne, M. Dewdney, the social worker attached to J.S. Collings practice in Richmond, alongside Collings himself, surveyed elderly people in Richmond to ascertain what their needs were, and similar local surveys were done in Sydney and Brisbane.97 It is a view in which ‘social’ aspects appear as undisputable and quantifiable, and it suggests that the ‘social’ may be integrated with the ‘physical and mental’ through the work of the social worker.
Dax conveys an impression of social study that contrasts with Stoller’s call for sociological and psychological research to provide insight into the complex interactions that he, together with psychiatrists Bower and Davies, saw underlying mental illness in elderly patients. However, despite advocating research into the experience of ageing, Stoller, it seems, did nothing to promote it. Herbert Bower, who appears to have had a genuine interest in opening up the topic of dementia for investigation in ways that were not dependent on biological investigations, has, as his most noted contribution to the body of gerontological knowledge that began to emerge in the 1960s, the idea for the ‘granny flat’. This publicly subsidised accommodation built adjoining the family home was intended to provide a way of acceding to the desire Bower discerned in elderly people to remain close to their family.98
95 The three areas were the family, retirement and legislation relating to pension entitlements, ibid. p.202-203. 96 Ibid, p.203. 97 It is interesting to note that Hutchinson’s survey, based on the notion that the status of the aged in society needed to be changed was not listed in Dax’s references. Dewdney and Collings’ survey was on a smaller scale than Hutchinson’s and free of ideas about social change, Living on the Old Age Pension, Hospitals and Charities Commission, Melbourne, 1965. The other two referred to by Dax were, ‘A Survey of the Needs of the Aged in Marrickville, N.S.W. by W.L. Robb, and K. Rivett, 1964, and in 1967, ‘A Survey of the Aged in Brisbane’, A.E. Hartshorn, Dax, 1966, op. cit. p.203. 98 H. Bower, ‘Aged Families and Their Problems’ in The Family in Australia, eds J. Krupinski & A. Stoller, 2nd ed, Pergamon Press, Australia, p.172-173.
188 Investigation of the experience of old age in the Australian community was, with the occasional exception, neglected in favour of a focus on service provision. The Psychology Department at the University of Melbourne was, it appears just as uninterested in researching the experience of ageing as was the Department of Psychiatry.99 Although there was some interest in the topic of old age in the Department of Social Studies at the University of Melbourne and in the sociology department at the newly established La Trobe University, in neither place was it part of a research program.100 The interest in old age was confined to those health professionals employed in the Geriatric Hospitals and the voluntary agencies, and the psychiatric service. Consequently the knowledge they produced was characterised by a concern with old people who needed assistance and with an orientation to service provision.
Institutional Stagnation Davies’ characterisation of the typical ‘geriatric’ patient as the ‘feeble old woman’ may have had the potential to nourish a distorted view of older females in general. However, any possibility of a psychiatry of old age exerting any degree disciplinary power in Victoria during the 1960s and early 1970s, was stifled by the continuing emphasis on institutional care in relation to infirm old people. Other psychiatrists may have been able to use the revival of the role of the state institution psychiatrist to cultivate their specialist fields, but practitioners interested in old age were unable to develop their role much beyond the point of improving institutional management. As had happened in general medicine and surgery, increasing technical competence and the greater availability of chemical
99 The most sustained and extensive research into the experience of old age began in 1965, in the Department of Psychology at the University of Queensland by Dr E. Harwood, Senior Lecturer and Dr G.F.K. Naylor, Reader. They began a longitudinal study, of 300 individuals aged between 65 and 95 years, focussing on the intellectual and emotional changes experienced by this group. Their research was presented at meetings of the Australian Association of Gerontology; E. Harwood, ‘Anxiety Levels in Old and Young – A Comparative Study’, pp.15-18, G.F.K. Naylor, ‘Some Aspects of Memory in the Aged’, p.19-20, Proceedings of the Australian Association of Gerontology, vol 1-2, 1969-1976. 100 At the 1965 Geriatrics Conference, L.J. Tierney, Reader in the Department of Social Studies at the University of Melbourne, spoke on the topic of the social relationships of old people. In 1967, Professor J. Martin, from the Department of Sociology at La Trobe University, addressed the topic, ‘The Place of the Aged in Society Today’. Martin’s contribution may have given G.V. Davies grounds for thinking that his wish would be fulfilled, that the close proximity of La Trobe University and Mont Park Hospital would provide the basis for ‘the first Australian Institute of Gerontology’, Davies, 1965, op. cit. p.312. Davies wish was ultimately fulfilled some twenty years later when a Gerontology Centre was established at the university. Tierney’s and Martin’s papers can be found as
189 therapies, meant that elderly adults were initially treated in a similar manner to younger adults. The psychiatry of old age was thus oriented towards the management of a remnant of patients for whom such treatment was not successful.
Even in respect to this patient group, in whom, with the exception of the geriatricians in the Geriatric Hospitals, no other medical practitioners were interested, psychiatrists were unable to establish the geriatric service as the principal form of hospital and medical provision for them. A survey by hospital social workers in 1967 highlighted the problems they faced in finding suitable care for infirm old people whose mental state caused them to be rejected by most providers of custodial care.101 Anna Howe’s study of long-term care provisions in Melbourne in the late 1970s, showed a diagnosis of ‘confusional state/senility’ in forty-three per cent of admissions. The relevance of this statistic to the period at the beginning of the 1970s may be disputed because, as Jan Carter notes in relation to such statistics, an assessment of ‘brain failure’ reflected the biases of the observer as much as the behaviour of the observed. Nonetheless it is at least an indication that confused thinking played a significant part in ensuring an elderly patient’s admission to long-term care, illustrating a need for the services psychiatrists advocated.102
The essence of the reforms Cunningham Dax introduced in the early 1950s was a shift in the approach to treating mental illness, away from institutional care to community. In the 1950s and 1960s he achieved some success in achieving this objective for other groups of patients, but in relation to old people there was absolutely no move away from institutional care.103 Lack of resources was one element in the failure of follows; Geriatrics Conference 1965, Geriatrics Conference 1956-1966, op. cit, Geriatrics Conference 1967, Geriatrics Conference 1967-1976, op. cit. 101 J.S. Lawson, Australian Hospital Services, A Critical Review, Gardner Printing & Publishing Pty. Ltd, Hawthorn, Victoria, 1968, p.21. 102 Howe, 1980, op. cit, p.82. A survey of provisions and the needs of old people suffering from ‘brain failure’, published in 1981, drew on a range of material published throughout the 1960s and 1970s, to estimate that between twenty and fifty per cent of places for care for the elderly were taken up by persons in this category, a number equivalent to the population of a city the size of Ballarat, for example, J. Carter, States of Confusion, Australian Policies and the Elderly Confused, Social Welfare Research Centre, University of New South Wales, No 4, 1981, p.10-11. 103 Robson, op. cit. p.243ff, deals with the question of what happened to the parts of the system that were not amenable to Dax’s ordering, for example, the lack of community back-up to de-institutionalization, p.257ff. Lack of ministerial support may also have been a factor as well as Dax’s refusal to ‘curry favour’ with politicians.
190 the development of psychiatric geriatric services. Seventeen years after Herbert Bower set about the monumental task of developing acute psycho- geriatric services in the antiquated Willsmere Hospital, C.G. Burt, then medical superintendent, included a terse note in the annual report of the Mental Health Authority recording the absence of ‘any reasonable facilities for an acute psychiatry of old age’.104 In the directory of services published by the Mental Health Authority in 1975 the facilities at Willsmere, inpatient, outpatient and day hospital were the only psychogeriatric services listed for the whole State.105
In addition to inadequate resources, psychiatrists were hamstrung in developing a practice in regard to mental disturbance in old age by the lack of awareness in the general community about their services. Even general practitioners were unaware of the services offered by psychiatrists, and ignorance was compounded in some cases by a persisting suspicion of psychiatric treatment on the part of both medical practitioners and their patients. The limitations on the use of psychiatric services were identified in a small study of the attitudes of general practitioners, to referring their patients for psychiatric treatment.106 A minority shared their patients’ view that such a referral was not acceptable either because mental disturbance in the elderly was not considered an appropriate matter for medical treatment or because of shame at having to make such matters public. Those who were prepared to consider this option were likely to be frustrated by the lack of general information, even within the medical profession, about the process of referral and the services that were available.107
104 Annual Report, Mental Health Authority, 1973, p.78. Under the Mental Health Institutions Act (1948) the Commonwealth contributed to the maintenance of patients. This provision expired in 1954, and was replaced the following year by a measure under the State Grants (Mental Institutions) Act whereby the Commonwealth matched expenditure made by the State government up to a maximum set by the Commonwealth. These subsidies were for capital purposes only and Victoria had exhausted its entitlement by 1960-61, Otto &Tierney, op. cit. p.17-18. 105 Mental Health Services in Victoria, 1975, Mental Health Authority, William St Melbourne, p.17-18. 106 B. Teltscher, ‘Misreferral of Patients to a Geriatric Hospital’, MJA, vol 1, 1968, p.218- 219. 107 A general practitioner would need to be particularly interested in the matter to take note of a small notice in the Australian Medical Association (Victorian Branch) Monthy Paper, January, 1973, to the effect that a summary of facilities provided by regional psychiatric services, was available, on application, from the Mental Health Authority.
191 Fundamentally, the division of hospital services between physical and mental disease did not serve the interests of an old person at risk of being committed to custodial care – the patient for whom services in both the Geriatric Hospitals and the psychiatric hospitals were intended. Davies illustrated this situation in a study he made of admissions to the mental hospital and to one of the geriatric units. Of 50 consecutive admissions to the mental hospital, 28 had major physical disabilities, and of 50 consecutive admissions to the Geriatric Unit at Caulfield Hospital, 23 patients had problems that called for admission to a mental hospital. To back up his claim for special hospital and medical services for this group of patients Davies quoted a recommendation of the World Health Organization that the provision of effective treatment for this group required a setting in which geriatrics (care of the aged) medicine and psychiatry were combined.108 The complete lack of interest amongst hospital doctors in providing appropriate hospital services for this group, or even acknowledging the need to do so, was clear in the report on hospital services in Victoria published in the mid-1970s. This inquiry was conducted by Sir Colin Syme and Sir Lance Townsend, both prominent members of the Melbourne medical world and the only reference they made to the needs of infirm old people, was an acknowledgment of the rehabilitation services provided in the Geriatric Hospitals. There was no mention of the failure of existing general and psychiatric hospitals services to address the needs of this group of patients.109
The provision of institutional care for infirm old men and women, whose capacity for independent living was impeded by confused thinking, did not diminish during the 1960s. The mental hospitals continued to take in elderly people who were unwelcome in other institutions. Medical administrators in this service, like their predecessors since at least the 1920s, continued to call upon administrators in these other sectors to develop a unified approach to the care of these people.110 The only alternative form of accommodation that had emerged since the early 1960s
108 ‘Points of View’, G. V. Davies, ‘The Relation of Physical and Mental Disease in Later Life’, MJA, vol 2, 1961, pp.152-154. Davies’ conclusion was reiterated in a survey conducted by the Planning and Research Branch of the Health Commission of Metropolitan Melbourne psychiatric hospitals in 1979, Carter, op. cit. p.10. 109 Commission of Inquiry Report, July, 1975, Hospitals and Health Services in Victoria, (Sir Colin Syme & Professor Sir Lance Townsend) Melbourne, p.73. 110 VPRS 4523/P2/1064/1979-45.
192 were the private nursing homes that sprang up around the suburbs following the introduction of a subsidy for long-term care by the Federal government in the early 1960s.111 This bureaucratic measure, an extension of the system of publicly subsidised voluntary hospital insurance, offered an alternative to mental hospital admission for some mentally disturbed old people and an avenue for discharging others.112 The removal of mentally disturbed old people from the mental hospitals was something to be applauded. However, their incarceration in smaller institutions without the benefit of any of the expertise that was available in the psychiatric hospitals by the late 1960s, was yet another indication of the reluctance of administrators and medical practitioners to address the specific needs of this group of elderly patients.
In the 1960s, admission to the nursing home did not require a medical certification of need. Where a medical practitioner was involved, it was the general practitioner. The State institution psychiatrists may have provided consultative services for those nursing home patients who had private medical insurance and whose GP was inclined to seek assistance in providing appropriate medical care for them, but the provision of specialist care was left to the discretion of the general practitioner. Until the introduction of a publicly funded, universal system of hospital and medical insurance by the Whitlam Labor government in the mid 1970s, old people who could not afford private medical insurance were only able to get specialist medical services in a public hospital.
111 By the time Carter published her survey in 1981, she was able to note that ‘in every state besides South Australia and Tasmania … the largest resource (for mentally disturbed old people) appears to be the private nursing home.’ Carter, op. cit. p.7. 112 The process of deinstitutionalisation that was inherent in the plans E. C. Dax had for reforming Victoria’s psychiatric services, was common to psychiatric services in Britain and America. It seems that the situation in Victoria, in relation to old people, fell somewhere between the experience in these two countries, both of which moved towards a similar provision of psychiatric care in the community rather than through institutionalisation, in the 1960s. On the whole, in England the over 65 year olds ‘did not constitute a disproportionate fraction of those discharged from mental hospitals’, possibly because there was nowhere else for them to go. In America the provision of publicly subsidised, unregulated, private nursing homes made it possible to almost completely eliminate old people from the State mental hospitals, A. Scull, Social Order/Mental Disorder, Anglo-American Psychiatry in Historical Perspective, University of California Press, Berkeley, 1989, p.312 and p.320; for conditions in Australia see Kewley, op. cit. pp.357-358.
193 The pressure on the publicly funded psychiatric services was such that only the most severe cases were admitted there.113 The deficiencies of the nursing home were made evident in Ellen Newton’s account of her time as a patient in a number of nursing homes in the eastern suburbs of Melbourne in the mid to late 1970s.114 Her description of nights ‘jagged with hideous sounds’, and the dismay, sometimes terror, invoked by the uninvited visitors wandering into her room, day and night, are a telling indictment of the failure of psychiatrists or the relevant state hospital authorities to make anything of the medical model developed in the psychiatric hospitals.
There can be no doubt that the provision of a subsidy for long-term care, introduced without reference to the State governments or to the medical practitioners who had a professional interest in the care of the infirm aged, prolonged the period during which this group was denied appropriate hospital and medical services. The needs of this group were overlaid by the interest of the State government in minimising its own expenditure in relation to the infirm aged by making the most of the Federal subsidy for nursing home care. The point made in the previous chapter, that this subsidy meant the Federal government shared an expense that would otherwise have been borne entirely by the State government, was even more the case in relation to mentally disturbed old people. The State government bore sole responsibility for the cost of psychiatric services whereas the Federal government contributed to the cost of general hospitals.115 However, in participating in a process whereby the infirm aged were decanted out of the mental hospitals, and into private nursing
113 The Pensioner Medical Service introduced in the early 1950s by the Liberal-Country Party government, provided free general practitioner services for eligible pensioners (Age and Invalid) but these people had to attend the outpatients department of a public hospital for the services of a specialist consultant. This arrangement led to the situation where old people were at risk of not receiving treatment they needed because of the difficulties involved in getting to one of these hospitals. Carter found it hard to discern any particular pattern as to whether a patient suffering from ‘brain failure’, the term she uses, was more likely to be placed in a Geriatric Hospital, private nursing home or mental hospital, although she concluded that patients were likely to be transferred to mental hospitals from private nursing homes when they became difficult to manage, Carter, op. cit. p.10. 114 E. Newton, This Bed My Centre, McPhee Gribble, Melbourne, 1979, p.146-148, p.184. 115 A representative of the Commonwealth Department of Health which administered the nursing home subsidy described the response on the part of State governments; there was ‘concerted action by some States to move busloads of people out of their mental institutions and into big boarding houses. They immediately approved these as nursing homes before we got into the act …’ House of Representatives Standing Committee on Expenditure, In a Home or at Home, (Chairman L. McLeay) Australian Government Publishing Service, Canberra, 1982, p.13.
194 homes, were psychiatrists collaborating with ‘the state’ as it sought to minimise its costs, and manage a ‘problem’ population to maintain a social order conducive to the capitalist mode of production?116
In Andrew Scull’s view it was the administrative techniques developed to manage a ‘community-oriented’ psychiatric service, techniques that were part and parcel of the emergence of psychiatry as a developed specialty, that formed the basis of psychiatry’s involvement in maintaining social order.117 In Victoria however, well into the 1980s, the scope for psychiatrists exerting their administrative capacity in relation to provisions for old people, was limited by the fragmented system of service provision, the reluctance of the state bureaucracy to recognise psychiatric expertise, and the subordination of psychiatry to general medicine and surgery in the organisation of hospital services. Psychiatrists might have been able to exert some influence in the provision of long-term care by setting up an alliance with the voluntary agencies. However, E.C. Dax’s insistence on addressing issues relating to the provision of long-term care in terms consistent with his professional view; that is, only after acute medical services had been established, and in relation to the need that was thereby identified, meant that even this limited form of cooperation in managing the ‘problem of the aged’ was eliminated. The infirm aged, ‘social junk’ in Scull’s terms were, in the course of the 1960s, transformed into a commodity from which entrepreneurs profited but psychiatrists did not. The exercise, contrary to Scull’s formulation was not an inexpensive one, but it was an expense that did not fall on the State government.118
116 Scull, op. cit. p.135. 117 Scull, ibid. p.31. 118 Scull, ibid. p.150.
195 Conclusion The failure of the Mental Health Authority, in the period between the late 1950s and early 1970s, to establish appropriate psychiatric services for old people whose needs could not be met through services for younger adults is understandable in light of the difficulties faced by E.C. Dax in implementing reform in the psychiatric hospitals. Confused old people were neglected because the combined effects of an overall lack of resources available to the Mental Health Authority, lack of central coordination to ensure prompt access to patients who did not fit into the organisation of hospital services around the division between mental and physical disease, and the introduction of the Federal government subsidy for nursing home care. In many respects the conditions necessary for the successful operation of geriatric services were beyond the control of psychiatrists. The revolution in psychiatric care that was set in motion in the early 1950s certainly did not bring the benefits to old people at risk of needing custodial care, that it may have done for other members of the community. It is also likely that the trend towards developing a biological model of mental illness ensured that the attempts of the few psychiatrists who were interested in mental deterioration in old age from a biographical perspective were sidelined.
Nevertheless there are aspects of the failure of psychiatrists to promote the cause of elderly patients that are not explained by outside elements. The doctors who promoted attention to the needs of elderly patients occupied influential positions – E. C. Dax was Chairman of the Mental Health Authority and Alan Stoller his Chief Clinical Officer. It might have been expected that the latter would have used his position to advance research into ageing in some fashion other than simply referring it to the social sciences. If the mental condition of migrants was regarded as a suitable subject for study at the Mental Health Institute, why not the mental condition of elderly Victorians? In relation to E.C. Dax, the question has to be asked as to why he did not encourage the voluntary agencies to develop special facilities for those old people who needed long-term care but who were unwelcome everywhere else. He did not hesitate to bring voluntary agencies into the work of providing special facilities for children with particular needs and Robson’s study of his tenure as Chairman of the Mental Health Authority stresses his ‘capacity to represent the interests of
196 the profession of psychiatry within the government and to use the media to communicate the vision of reform to the public’.119 It is unlikely there was no interest at all amongst the agencies.120 The conclusion can only be drawn that Dax’s insistence on linking institutional provision with the development of acute care facilities and community based welfare provisions, led to his taking a stand against the encouraging institutional provision by voluntary agencies. The result was, however, that the expansion in institutional care, unregulated and unsupervised, in the private nursing homes, left the recipients of such care bereft of what expertise there was in the community. Psychiatric expertise remained confined to the psychiatric institutions, not exerting even the minimal influence that the geriatricians had through their interactions with the voluntary agencies.
119 Robson, 2002, op. cit. p.70. 120 In the early 1980s the Uniting Church, one of the voluntary groups involved in providing age-specific services, did take steps towards assessing the needs of mentally confused old people by sponsoring research into the incidence of dementia, VPRS 4523/524/8670; VPRS 4523/407/8087; see also Howe, 1997, op. cit.
197 CHAPTER 5 GERIATRICS AS MEDICAL WORK
Introduction The focus in this chapter shifts away from Victoria to the national arena. The reason is that when, in the early 1970s, Victorian ‘geriatricians’ had the opportunity to develop their institutional role as a field of special interest, defined in terms of a specific body of knowledge and training, it was because of changes at the national level, changes in which the Victorians were onlookers, not active participants. This chapter surveys an extensive area of activity in relation to health and welfare services in the Commonwealth and the States. Activities that include the provision and funding of age-specific welfare services; the meaning of ‘geriatrics’ in the different state environments; relations between federal and state governments; and the efforts made by a segment of the medical profession to address the deficiencies they perceived in the existing organisation of medical services. Among such deficiencies were the failure of medical training to equip general practitioners to deal with the chronic illness and disability that constituted much of their workload; and the failure to develop an organisation of health services in the Australian context that would facilitate the treatment of such conditions. My over-riding aim here is to show how the providers of geriatric services in their various state- bound locations sought to establish geriatric medicine as a field of practice or specialty defined in terms of specific training, and then to identify the possibilities for doing this that appeared in the changing professional and political environment of the early 1970s .
The Victorian doctors who supervised the transformation of Benevolent Homes into Special Hospitals for the Aged were part of a small, nation- wide community of medical practitioners who provided services for the infirm aged in their respective states. The defining characteristics of this community were: salaried employment in state funded institutions; local adaptations of the British geriatric service; isolation from the mainstream of medical work; and, in some cases, positions in the state’s Public Health bureaucracy as Directors of Geriatrics. In their role of providing services for the infirm aged, services based on a socio-medical model of service, these medical practitioners found more in common with an emerging field
198 of care of the aged than with their medical colleagues providing personal, curative medical services.
In this field medical practitioners held positions of importance, were prominent participants at ‘field’ gatherings like the Geriatrics Conferences, and took the lead in establishing the Australian Association of Gerontology. But they did not succeeded in diminishing the emphasis on institutional provision for the infirm aged. The growth of the private nursing home industry throughout the 1960s, on the basis of subsidies provided by the Federal government, was graphic testimony to the failure of these medical practitioners to establish the ‘geriatric service’ in their respective states, as the principal means of managing the needs of candidates for custodial care. Their failure was not so much at the state level; the appointment of doctors as Directors of Geriatrics in some state health bureaucracies suggested state governments were not altogether deaf to the advocates of geriatric services. It was more a failure in gaining a foothold in mainstream medicine and in policy formation in the Federal government.
In the early 1970s this situation changed as a segment of the medical profession, concerned to address problems of ill-health they believed were neglected in the existing emphasis on individualised, curative medical services, gained a foothold in making health policy at the Federal level. Once again social medicine provided a model for the implementation of socio-medical services, through the work of Thomas McKeown. McKeown, who had replaced John Ryle as leader in the discipline of social medicine in Britain, visited Australia in the late 1960s. His ideas were particularly influential in the work of Sidney Sax, who led the revival of social medicine in Australian through his work in the health bureaucracies of New South Wales and the Federal government. The revival of social medicine certainly provided conditions essential to establishing the field of geriatric medicine as a medical specialty. However, the emphasis in this revival on the rational management of national resources – human and technical – through community-based organisations, did not always work to the advantage of doctors who sought to establish age-specific, hospital-based services.
199 The Australian Scene The following survey of developments in the other states is intended to provide a brief outline of the field of ‘geriatrics’, as it emerged during the 1960s. A point that needs to be made at the outset, one that is equally applicable to all the states, is that these activities took place on the margins of ‘mainstream’ health services everywhere in Australia. The ‘problem of the aged’ featured prominently in public discussion and, by the early 1970s, a sizeable amount of public funds was spent on the provision of services for the infirm aged. However, despite the rhetoric and financial commitment, the provision of special hospital and medical services for old people at risk of becoming dependent was not prominent in policy related to the overall provision of hospital and medical services in the states.
The record of the annual Geriatrics Conferences, sponsored by the Hospitals and Charities Commission in Victoria, is useful for charting the emergence of the field of geriatrics in that state. It also offers an insight into similar activities in the other states as their representatives were invited to participate in the Conferences. By and large these representatives were medical practitioners but, as noted in chapter three, they were only one group amongst a number of potential experts in relation to services for the infirm aged. The others included social workers, nurses, and institutional managers, all of who were in the process of establishing a professional role in this emerging field.1 Nevertheless, medical practitioners played a leading role in presenting a new form of expertise at the conferences where they appear as hosts, speakers and leaders of discussion groups. A constant theme in all these activities was the ‘Geriatric Service’ as the most appropriate form of hospital and medical service for infirm old people, and in this respect, the model promoted in the growing field of activity around the care of the aged was a medical one. It was questionable however, whether this would necessarily entail the development of the geriatrician as a specialist practitioner in the field of health and sickness in old age.
1 See Appendix 1.
200 Richard Gibson, in keeping with his work in establishing the first form of geriatric service in Australia at the Royal Newcastle Hospital in New South Wales, was a frequent visitor to the Victorian conferences from the first one in 1956.2 By 1964 various ventures were underway in all the states, to replicate his model, and representatives of the states attended the Geriatrics Conference of that year to describe their efforts. The 1964 Geriatrics Conference thus provides a convenient introduction to the range of activities throughout the country that were encompassed within the term ‘geriatrics’. The marginal status of the Victorian ‘geriatricians’, was especially clear on this occasion. Elizabeth Johnson, officer in the Geriatrics Division of the Hospitals and Charities Commission represented Victoria and the medical services provided in the Geriatric Hospitals were listed as just one aspect of a varied and fragmented range of activities included in the category ‘care of the aged’.3
Tasmania and South Australia were represented in 1964 by the Secretary of the Launceston General Hospital and the honorary secretary of the Central Methodist Mission in Adelaide respectively. Both described the development of institutional settings in which different types of accommodation were provided, ranging from independent living to long- term care. In both states, some restorative treatment was offered, and in Launceston, domiciliary services were also provided. The main difference between them was that the latter was attached to the Launceston General Hospital, whereas the Adelaide project was an independent, church run enterprise which, although it provided restorative treatment, was not connected to a hospital. In both states there were prominent medical spokesmen – Dr A. M. Forster in Tasmania, and Dr Collin Robjohns in South Australia.4 Neither of these practitioners referred to the nature of the medical role in the provision of the services they were involved in. This suggests that their main preoccupation was the provision of services
2 Geriatrics Conference, 1956-1966, op. cit. 3 Geriatrics Conference 1964, pp.77-80, Geriatrics Conference, 1956-1966, op. cit; see also Chapter Three. 4 After leaving the Queen Elizabeth Centre at Ballarat, where, as medical superintendent he had established rehabilitative treatment, Robjohns went to Aldersgate Village, the institution run by the Methodist Central Mission in Adelaide.
201 for infirm old people, services that certainly had a medical component but were not specialist medical services.5
Queensland and Western Australia were exceptional because the introduction of geriatric units into acute hospital settings was associated with a clearly defined medical orientation to sickness, albeit one that was dominated by an overall emphasis on curative medical services. The Marjory Warren Geriatric Unit at the Princess Alexandra Hospital in Brisbane, a purpose-built unit, was but one aspect of the conversion of an old chronic diseases hospital into a modern general hospital.6 The unit was in the charge of P. G. Livingstone who had undertaken his postgraduate training with Marjory Warren at the West Middlesex Hospital, and it was staffed by doctors and nurses as part of their rotation through all hospital departments.7 This development took place within a system of hospital services funded and provided by the state government and administered by the Department of Health and Medical Services established by Sir Raphael Cilento in the 1930s.8 Cilento, worked from a perspective in which medical services combined preventive and clinical elements and hospitals were organised to provide services rather than beds.9 The Geriatric Unit, instigated by Cilento’s successor, Sir Abraham Fryberg, demonstrated all these attributes.10 Livingstone was also
5 Dr Forster’s views may be discerned in his opening address at the 1976 meeting of the Australian Association of Gerontology. He emphasised the needs of the elderly, including medical care, rather than the specific character of that medical work, Proceedings Australian Association of Gerontology, vol 2, no 4, 1976, p.199-200. Collin Robjohn stressed that ‘care of the aged, especially the frail aged is a medical matter, not something to be handed over to either the Nursing Profession or to lay administration’ but did not define the character of that medical role, ‘Care of the Aged’, Newsletter of the Australian Association of Gerontology, vol 1, no 5, 1967, p.36-37. 6 See Chapter Two. 7 Livingstone himself described these developments at the 1962 Geriatrics Conference, Geriatrics Conference, 1956-1966, pp.78-87. 8 See Chapter Two. In Queensland, although hospitals were initially established along the lines of the voluntary model provided by the English system, problems in funding and management, combined with a Labor government inclined to favour the provision of hospital services by the state, led to the situation where, in 1944, a Labor administration finally achieved its aim of controlling the public hospital system. J. Bell, ‘Queensland’s Public Hospital System: Some Aspects of Finance and Control’, in J. Roe, Social Policy in Australia, Some Perspectives, 1901-1975, Cassell, Australia, 1976. 9 Gould-Fisher, op. cit. p.103-4. See Chapter Two. 10 Fryberg was appointed Director-General of Health and Medical Services in 1947, having worked with Cilento in the 1930s, R. Patrick, A History of Health & Medicine in Queensland 1824-1960, University of Queensland Press, St Lucia, Queensland, 1987, p.112. The Division of Geriatrics was created in 1961, ‘for the express purpose of improving the health and welfare services for senior citizens across the whole range of needs including the provision of hospital care, accommodation in nursing homes’, S.D. Tooth, ‘Progress in Geriatric Care in Queensland’, Proceedings Australian Association of Gerontology, vol 2, no 1, 1973, p.3.
202 appointed Director of Geriatrics in the Department of Health and Medical Services with responsibility for developing similar services in other hospitals.11 His success in doing so was limited by a lack of domiciliary services in the state so this process was patchy.12
In 1964, developments were also at an early stage in Western Australia when R. B. Lefroy described them to the Conference. Lefroy, a physician, relinquished a position at the Royal Perth Hospital and in the Department of Medicine at the University of Western Australia, to take an appointment as Director of Geriatrics in the Department of Public Health.13 His promotion of geriatrics was influenced by the approach Eric Saint, foundation Professor of Medicine at the University of Western Australia, brought to his teaching role in the newly established medical school at the University. Saint, as a medical educator, sought to establish ‘social medicine’ as part of the intellectual orientation of students by cultivating in them ‘an attitude of mind which views the pattern of disease in a population as a reflection of the cultural structure of society and the occupational pursuits of its members’.14 From this perspective, the neglect of infirm old people in the acute hospital reflected a ‘cultural’ disposition amongst doctors to view infirmity in old age as inevitable and the provision of custodial care as the principal response. The introduction of an age-related service into the acute hospital as Lefroy planned, was
11 In 1964 Livingstone’s contribution to the conference was read by a representative, H. N. Acklom, Geriatrics Conference 1964, Geriatrics Conference 1956-1966, op. cit, p63. 12 R. B. Lefroy, 1988, op. cit, p 60-61. Livingstone himself may have provided this assessment to Lefroy. 13 Geriatrics Conference 1964, pp 65-70, Geriatrics Conference, 1956-1966, op. cit. Lefroy had joined Eric Saint who had been appointed to establish a medical school at the university in 1957, as Associate Professor. In the history of the medical school Lefroy is described as a ‘superlative clinical teacher’, N. Stanley, ed. Faculty of Medicine, The University of Western Australia, The First Quarter Century (1957-1982), Faculty of Medicine, University of Western Australia, 1982, p59; Lefroy, 1988, op. cit. p.65. 14 See Chapter Two for an outline of social medicine; R. B. Lefroy, 1998, op. cit. Introduction, also E. G. Saint, 1955, op. cit. pp.161-165. Saint later noted the ‘development of style in the teaching hospital’ as one of three achievements of the early years of the medical school, ‘A Coming of Age’, Lefroy, 1998, op. cit. p.127. Saint went from Western Australia to the inaugural position of full-time Dean in the Faculty of Medicine at the University of Queensland.
203 simply a case of recognising the needs of this group of patients by providing them with a hospital environment in which they could be treated and recover at a pace dictated by their needs, not those related to the management of the hospital.15
It was not until the 1972 conference that Lefroy was able to describe the opening of a purpose built geriatric unit with 120 beds at the Sir Charles Gairdner Hospital in that year.16 Lefroy also faced difficulties in aligning hospital and domiciliary services. He decided it would be unrealistic to introduce separate domiciliary services operating out of the hospital when an efficient organisation already existed (providing nursing care, home help and physiotherapy), in part because he believed doing so would disturb the relationship between the general practitioner and the patient. The other side of this arrangement was that he then had to develop a relationship with the agency that provided domestic and nursing services in private homes (Silver Chain), and with the general practitioners in the area, so the services they provided could be aligned with those provided by the hospital.
Bruce Ford attended the 1964 Geriatrics Conference and described the service he had developed at the Canberra Community Hospital. While working as a general practitioner in Canberra, Ford also held a position as medical officer at this newly built hospital where he was commissioned to develop a Department of Physical Rehabilitation. As he told the conference, this step was taken to deal with the problems posed in the management of the hospital by the occupation of 12 per cent of its beds by
15 Geriatrics Conference, 1964, pp.65-70. Soon after Saint arrived in Perth he published a study showing how unsatisfactory it was to provide treatment for disease that focused solely on services provided in hospital without attention to other conditions that affected the health and well-being of patients. The study looked at discharged patients and found a significant number of cases where the treatment provided in hospital was undone as a consequence of the conditions in which these people lived, E.G. Saint, ‘Medical Morbidity in a General Hospital’, MJA, vol 2, 1960, pp.601-608. 16 Geriatrics Conference, 1972, Geriatrics Conference 1966-1976, op. cit. The Sir Charles Gairdner Hospital was, in the mid 1960s, ‘still struggling to emerge as a general hospital’ from its previous existence as a tuberculosis hospital, and Lefroy hoped it would ‘be the first to achieve a geriatric hospital service in its fullest meaning’ because it had not been fully committed to specialised medicine, Geriatrics Conference 1964 op. cit.
204 a group, as he described them, of ‘neglected’, or, he corrected himself, ‘… not … neglected – inadequately occupied elderly people’. In the 1960s the first residents of the capital city were beginning to age and in response community groups and voluntary agencies began to build accommodation to provide for their needs. In addition there was a District Nursing Service administered by the federal Department of Health and a Housekeeping Service administered by the National Council of Women. Perhaps because of the lack of long established interests in both the provision of hospital and welfare services, and the smaller population, Ford was able to establish a department that acted as a ‘bridge’ from hospital to community in a fashion not so easily achieved in Melbourne and Sydney.17
The success of the services offered at the Royal Newcastle and the Canberra Community Hospitals showed what could be achieved in establishing a geriatric service in a community of moderate size. The situation was more complex in the large capital cities where it was not so easy to establish personal relations between institutions and community- based domiciliary services, nor between the various medical practitioners who may be involved. In addition demand was greater.18 It also suggests that the provision of such a service did not necessarily entail the development of the role of physician geriatrician. The medical superintendent of the hospital in Newcastle, Dr C.J. McCaffrey, made it clear, when he accompanied Richard Gibson to the 1961 Geriatric Conference, that the provision of medical rehabilitation services was simply another level of general hospital care that, as it happened, treated mostly elderly people.19
17 B. Ford, Geriatrics Conference, 1964, pp.41-46. 18 When John Shepherd, medical superintendent of Mount Royal, and the manager of the hospital, M.E. Atkinson, visited Richard Gibson’s geriatric unit at the Royal Newcastle Hospital, in 1963, they both concluded that while his achievements were to be admired, it would be difficult to reproduce such a service in Melbourne where patients were admitted from widely scattered areas and demand was greater. Personal Papers, Dr John Shepherd. 19 Geriatrics Conference 1961, op. cit. pp.24-26. See also Chapter Two.
205 Bruce Ford also worked within the framework of medical rehabilitation. Possibly his interest in this type of work was aroused in the early 1960s when he worked as a medical officer at the Prince Henry Hospital in Sydney, where plans were underway to introduce rehabilitation services for stroke and poliomyelitis patients.20 It is likely that by then he had established contact with the small group of doctors described in chapter two, who lay the groundwork in New South Wales for developing medical rehabilitation facilities in the 1950s.21
At the same time in New South Wales in the late 1950s, the Director- General of Public Health, Dr C.J. Cummins, had begun to establish special hospitals for the aged in several hospitals under the control of the State government. John Lindell, Chairman of the Hospitals and Charities Commission in Victoria, was a member of the Health Advisory Council of New South Wales, which had recommended this.22 Unlike the Geriatric Hospitals in Victoria, the State hospitals in New South Wales were under medical control and there appears to have been more generous funding available for the development of age-specific services. When Geoffrey Hughes, deputy superintendent of Lidcombe Hospital attended the 1960 Geriatrics Conference he commiserated with Collin Robjohn, then the medical superintendent at the Queen Elizabeth Centre at Ballarat, who had
20 Bruce Ford was medical officer at Prince Henry Hospital before his move to Canberra. At Prince Henry, it appears from the final pages of the history of the hospital, that in the early 1960s there were plans to establish rehabilitation services, G. Caigen, ed, A Coast Chronicle, The History of the Prince Henry Hospital, The Board of Prince Henry Hospital, Sydney, 1963; B. Ford, The Wounded Warrior and Rehabilitation, The Alfred Healthcare Group, Caulfield General Medical Centre, Melbourne, Australia, 1996, p.137. 21 Leigh Wedlick, medical officer in charge of the physiotherapy department at the Royal Melbourne Hospital noted in an article published in 1957 that the Association of Physical Medicine, formed in the mid 1940s, had added ‘Rehabilitation’ to its title, L. Wedlick, ‘The Physical Medicine Department in Hospital Service’, MJA, vol 2, 1957, p.718, see also Chapter Two. 22 An early indication of the intention to introduce geriatric services in New South Wales may be found in a report compiled by G. Procopis, a medical officer at Lidcombe Hospital, based on what he had seen in the services developed by Marjory Warren and her colleagues in England, cited by S. Sax, ‘Perspectives on the Development of Gerontology in Australia’, Proceedings 20th Annual Conference Australian Association of Gerontology, 1985, p.7. Procopis’ report was followed by the report of the Advisory Committee which is outlined in an editorial, ‘Care of the Aged and Chronically Ill’, MJA, vol 2, 1960, p.587- 588; Dr Cummins attended the 1962 Geriatrics Conference and gave a personal account of the proposed changes in which he noted John Lindell’s presence on the Advisory Committee. A note in The Age newspaper, 13/6/50, suggests that a similar committee may have been established in Victoria as it refers to a committee formed two years previously and asks what has been done. There is no mention of such a committee in the files of the Hospitals and Charities Commission, VPRS4523/P1/260/2242.
206 lamented the poor facilities at his disposal.23 Hughes reported that Lidcombe had the medical equipment ‘of a standard comparable with that of a first-class hospital’, and facilities that included a Department of Physical Medicine where the ‘rehabilitation potential’ of every applicant for admission could be investigated, and an Institute of Clinical Pathology and Medical Research to foster clinical expertise in the diseases of old age.24
It is likely, however, that despite its greater facilities, Lidcombe Hospital functioned in much the same fashion as the Geriatric Hospitals in Victoria. When Hughes stressed the investigation of every applicant for admission and their classification and placement according to their needs, he did not broach the question of how potential patients came to be referred for admission. The lack of any organised link with the acute hospitals, and Lidcombe’s established role as a chronic disease hospital providing long- term care, meant that its function was limited to providing rehabilitation treatment for patients who could not be discharged. In this context also, the term ‘geriatrics’ referred to the provision of institutional care.
When Sidney Sax addressed the Geriatrics Conference in 1964, it became clear that the meaning of geriatrics in New South Wales was beginning to shift. 25 Sax, a South Africa-trained doctor had arrived in Australia in 1960. His qualifications included membership of the Royal College of Physicians of Edinburgh and a Diploma of Public Health. Having decided against making a home in Melbourne, his first port of call, he joined the Department of Public Health in New South Wales and after a stint as a hospital based doctor, he was appointed Director of Geriatrics when that position was created in the early 1960s. This marked the beginning of a distinguished career in health administration in both state and federal spheres of government.
23 G. C. Hughes, ‘Medical Aspects of Longer Living’, Geriatrics Conference 1960, p.106, Geriatrics Conference 1956-1966, op. cit. A brief outline of the history of Lidcombe Hospital may be found in footnotes to Chapter Three. 24 It was these facilities that made it possible to host a conference at Lidcombe in 1965 on ‘The Clinical Disorders of Old Age’, Newsletter of the Australian Association of Gerontology, vol 1, no 2, 1965, p.5. 25 S. Sax, Geriatrics Conference 1964, p.60-62, Geriatrics Conference 1956-1966, op. cit.
207 Sax spoke about a range of measures introduced in New South Wales, many of them similar to those in Victoria. The Old People’s Welfare Council, like its Victorian counterpart, was active in encouraging the establishment of local social clubs for elderly people with the aim of alleviating problems of loneliness, isolation and poor nutrition. The state government and the voluntary agencies were establishing a range of purpose-built accommodation for old people who were well and the number of nursing home beds in the state had expanded to around 12,000, for those who needed permanent care. The drawback was, that, with the exception of the service at Newcastle, all the innovations were limited in their effectiveness by lack of coordination. Sax did not refer to the changes Hughes had so proudly spoken of a few years earlier, apart from a passing remark to the effect that unfortunately the infectiousness of ideas about the special needs of old people did not show any signs of developing into an ‘epidemic’ of services. This comment implies that the state hospitals had not become essential transit points for candidates for custodial care, and that the idea of classification according to degree of infirmity and potential for rehabilitation had not been taken up by the church and voluntary agencies.26
As Director of Geriatrics within the Department of Public Health, Sax went on to outline to the conference the approach he intended taking. He stressed the lack of coordination between the various hospital and welfare services provided in the state. In response to this situation, he had formed a consultative committee for ‘the care of the aged’ comprising those groups whose interest in this matter arose from their activities in the community – representatives of the Australian Medical Association, local government, the New South Wales Old People’s Welfare Council and the state government. This approach implies that ‘geriatrics’ was principally a matter of coordinated community-based welfare services related to the needs of the elderly.
26 One exception was the Church of England Nursing Home, ‘Chesalon’. The rehabilitation services provided there were described by E. Biven (Physiotherapist) and A. Fallon, (Medical Officer) in ‘Geriatric Rehabilitation’, MJA, vol 1, 1966, pp.1081-1088. These services were most probably limited to those admitted to the home, they were not part of a classifying and treating, hospital-based medical service.
208 Sax clarified this interpretation in an address to a meeting of the New South Wales Gerontological Society, not long after speaking at the Geriatrics Conference. He began by defining geriatrics in a manner that, he said, went beyond the standard understanding of it ‘as a branch of medical science dealing with old age and its diseases’. Geriatrics, was ‘concerned as much with ability or its loss as with the diseases that are related to disability, and as much with the effect on the individual of the social and political sciences as with the effect of the medical spectrum’.27 These comments on the nature of geriatrics reflect ideas similar to those found in John Ryle’s description of social medicine as the ‘ ‘third epoch of prevention’, the previous two having been first the sanitary era and second, the attack on chronic diseases such as tuberculosis and venereal disease’. The concern in the third era is to ‘identify the social causes of health and to construct it through socio-medical reforms’.28 The socio- medical reform in Sax’s proposals was the coordinated provision of welfare services within a regional area so the medical care of elderly people at risk of needing custodial care could be linked into specific welfare services.
The connection between Sax and Ryle may be traced in the influence exerted by the advocates of social medicine on the training program for medical officers of health in Britain, in the late 1950s. Through the courses taught in the Public Health Diploma they sought to redefine the meaning of administration in public health to include ‘strategies for the health services as a whole’, instead of the everyday administration of the services for which the medical officer of health was responsible.29 Sax’s Diploma in Public Health was gained in South Africa, but his subsequent career as medical bureaucrat in both state and federal spheres of Australian government, clearly shows the influence of British ideas of public health administration, especially in his promotion of forms of hospital and medical services based on a socio-medical definition of health. Not that this precluded a definition of geriatrics as a specific form of medical work: Sax himself published an article defining geriatrics in these terms in
27 S. Sax, ‘Modern Horizons in Geriatrics’, Newsletter of the Australian Association of Gerontology, vol 1, no 3, 1966, p.1. 28 Porter, 1993, op. cit. p.252. 29 J. Lewis, What Price Community Medicine? The Philosophy, Practice and Politics of Public Health Since 1919, Wheatsheaf Books, Brighton, Sussex, 1986, p.58.
209 1965.30 However, from his point of view as health services administrator, geriatrics referred to community care for the elderly – it was left up to other advocates of geriatrics as medical work to establish the conditions for their definition to prevail.
Lefroy also defined geriatric medicine in an article published in the mid- sixties.31 The typical patient that he and Sax described, had already been discussed by the Victorian psychiatrist, G. V. Davies, in his 1961 study, as one who was ill-served by the division between mental and physical illness in hospital and medical services.32 Sax and Lefroy also described this patient as not fitting easily into existing hospital services, being ‘often confused, they misunderstand and are misunderstood, they may lack normal means of communication, and their rate of recovery is slow. … (in the general hospital ward) … Though they share the high standards of technical care (given to younger adults), they may not receive the almost continuous, always time-consuming close personal supervision that they need to be restored to independence.’33 Sax and Lefroy agreed this group ought to be treated within the general hospital, in a department devoted to the purpose and consisting of beds for assessment, rehabilitation and permanent care, outpatient clinic and day hospital.34
Lefroy’s and Sax’s definitions, however, differ in one significant respect. Sax made a distinction between this unit and those sections of the hospital where treatment was provided during episodes of acute illness.35 Lefroy on the other hand, advocated the provision of acute treatment within the geriatric unit. Old people, he wrote, ‘differ not so much in what they need during this assessment stage, as in the extent and the rate to which they respond to “acute” treatment’. It is because these patients do not fit into the ‘normal’ response to treatment during the acute phase of illness – their
30 Sax, 1965, op. cit. 31 Sax, ibid, and R. B. Lefroy, ‘The Medical Care of the Elderly’, MJA, vol2, 1966, pp.204- 210. 32 G. V. Davies, 1961, op. cit. pp.152-154. 33 Sax, 1965, op. cit. p.27, Lefroy, 1966, op. cit. p.205. The ‘close personal attention’ these old people needed to ensure their recovery from illness was in fact the norm of nursing care in the late nineteenth and early twentieth century when it was the most effective response to serious illness, J. McCalman, 1998, op. cit. p.73ff. 34 The term assessment was used to describe a process of diagnosis which combined a delineation of an elderly person’s physical, mental and social condition and it implied that the restoration to independence was the aim of medical treatment in addition to rectifying physiological abnormalities, Lefroy, 1966, op. cit. p.204-205. 35 Sax, 1965, op. cit. p.27.
210 response is slower, cure less likely – that they are at a disadvantage in this setting. The restorative phase cannot be so readily distinguished from the acute phase and ‘it should be continued by the same doctors and social workers as attended him in the acute phase ….’36 In a later article Lefroy also outlined the need for the geriatrician to be involved in supervising the provision of long-term, or as he preferred to call it, ‘permanent’ care, and the necessity for such facilities to be attached to a general hospital so that elderly patients who could not be restored to any degree of independence would be cared for in an environment where high standards of medical and nursing care were the norm. The point was that this group of patients would then receive attention on the basis of their needs, not the need of the acute hospital to empty its beds as quickly as possible.37
The Field of Geriatrics The various medical activities that came under the heading of ‘geriatrics’ in Australia in the 1960s show no definite and clear line of development, rather they reveal a number of possibilities as yet unrealised. The uncertainty of the nature of geriatrics as medical work, and the isolation of these practitioners from mainstream medicine, contrasts with the strong growth of the field of care of the aged in general, the field in which these doctors sought to establish their authority. In promoting the geriatric service as a means of providing appropriate support for dependent old people, medical practitioners found common cause with the many community groups, which, from the 1950s on, began to direct their activities towards the needs of the elderly. However, despite the prominence of medical practitioners in certain aspects of the field of care of the aged, they failed to secure the support they needed to minimise institutional care.
The plight of infirm old people in the early 1950s has already been described.38 Other elderly people also experienced problems that brought them to public attention. Those who perhaps had always lived in some degree of poverty found it increasingly difficult to maintain an adequate diet, cleanliness and warmth on the Age Pension if they did not have
36 Lefroy, 1966, op. cit. p.205. 37 R.B. Lefroy, ‘Permanent Care of Elderly People in Institutions’, MJA, vol 2, 1969, pp.707-712. 38 See Chapter Two.
211 family or friends to assist them. The overall postwar shortage of housing in the capital cities and an inflationary economy led to the situation where even those who were better off found it hard to manage on a fixed income. Possibly also the rise in living standards that came with postwar prosperity made the conditions in which some old people lived conspicuous in a way they hadn’t been previously. While old people had their strength, were able to see and hear clearly and to get about easily, changing social and economic conditions could be accommodated. However, when they lost the capacity to struggle in crowded shops, to hunt around for bargains, to keep up a supply of fuel for cooking, washing and keeping warm, their overall wellbeing suffered.39
The basis for a common interest between the medical advocates of the geriatric service, and groups such as the state Old People’s Welfare Councils that took on the task of promoting the interests of the elderly in postwar Australian society, lay in their joint concern to promote the integration of elderly people into the society around them. Medical practitioners aimed to diminish the use of institutional care by fostering the ideal of a ‘productive old age’ through the rehabilitation of old people who already experienced a degree of dependence, and the prevention of disability in those who were fit, by emphasising the value of activity and engagement. The voluntary agencies had as their objective the aim of showing ageing people in general ‘how to preserve their integration in society’.40 In each state, the medical advocates of the geriatric service were aligned with State government departments to varying degrees. Victoria was at one end of the spectrum in that the state government subsidised but did not provide hospital services directly and Queensland at the other, with its publicly funded hospital service. New South Wales fell in between. However in relation to the community-based welfare services that were necessary for a geriatric service to function, doctors everywhere
39 Current Affairs Bulletin, 1950, op. cit, 119; Garton, op. cit. p146; The Current Affairs Bulletin was issued fortnightly. It was developed by the Australian Army Education Service as it took on the task of converting fighting men into citizens with a sense of communal responsibility, able to ‘think intelligently’ about postwar reconstruction. The Bulletin continued to be published after the war by the Commonwealth. Many educators urged sn extension of the Army Education Service into the civilian population to equip adults as a whole to participate as responsible citizens in the reconstruction of postwar Australian society, a venture that also saw the establishment of the Council of Adult Education in Victoria in 1946, Brown, 1995, op. cit. pp.168-173. 40 Larkins, 1956, op. cit. p.23 and the introductory remarks by Archdeacon G. T. Sambell, Geriatrics Conference, 1957, p.27, Geriatrics Conference 1956-1966, op. cit.
212 were obliged to cultivate a common interest with voluntary agencies and community based groups. It was these autonomous bodies that emerged as providers of many of the services and forms of accommodation necessary for the effective operation of such a service.
The provision of welfare services by voluntary groups was a long established custom in all the states. Even where state governments were more disposed to play an active role in the provision of services, voluntary groups were encouraged to extend their role, as a result of two apparently ad hoc decisions by the federal Menzies’ government. The first was the introduction of a subsidy for providing purpose-built accommodation for well old people through the Aged Persons Homes Act (1954), and the second was the subsidy for the provision of long-term care - the Nursing Home Benefit - which became available in early 1963. Both forms of subsidy provided the means for extensive institutional development by church and voluntary agencies and a burgeoning private enterprise in the provision of long-term care. State governments, to a greater or lesser extent, also assisted local groups to develop services through special funding measures. The effect was that a not insignificant stream of public funding began to be absorbed into a range of fragmented community- based activities as individual groups responded to their particular perception of need without reference to existing services, nor indeed to how potential recipients may have construed their needs.41 It was the
41 In Victoria, for example, where the State government assisted Local Government agencies and community groups to provide services, there were around 100 organisation registered with the Hospitals and Charities Commission as recognised recipients of government aid in 1960. By the early 1970s the number had grown to around 500, Geriatrics Conference 1960, p.47 and Geriatrics Conference 1973, p.24, Geriatrics Conference 1956-1966, op. cit. and Geriatrics Conference 1967-1976, op. cit. Subsidies provided through the Aged Persons Homes Act, from its introduction in 1954 to the end of the financial year 1970-71, amounted to around $148 million, allocated throughout Australia to voluntary agencies, Kewley, op. cit. p.476. By 1972, the nursing home subsidy introduced by the Commonwealth in 1963, accounted for ‘almost three times as much as the expenditure … on Commonwealth hospital benefits for insured patients.’, Kewley, p.536. In relation to the provision of services without reference to how potential recipients may have perceived their needs, in Victoria, Elderly Citizens Clubs were established following a decision made by the Old People’s Welfare Council in Victoria, following their English counterpart, not a demand from the elderly people in the local government areas where they were built. Where elderly people did organise themselves it was in order to protect any erosion of pension benefits, B. Gilsenan, ‘The Involvement of Older Adult Organisations in the Policy Making Process in Australia’, Hons. Thesis, Department of Political Science, University of Melbourne, 1999. Provisions for the aged in the form of pensions and subsidies for long-term care and purpose-built housing stood out in a period when overall welfare spending was low, even if it was insufficient to keep some old people out of poverty, G. Gray, ‘Social Policy, in The Menzies’ Era, A reappraisal of Government, Politics and Policy, eds S. Prosser, J.R. Nethercote, & J.
213 fragmentation and proliferation of such services that led Sidney Sax to tackle the problem of coordination as one of the principal initiatives in his role as Director of Geriatrics in New South Wales.
The multifarious enterprises that began to appear in all the states, beginning in the 1950s, were identified by their providers as being responses to problems experienced by old people. However apart from the association with age – always defined as age of eligibility for the Age Pension – the common factor amongst these providers was their individual association with the federal government; an association that increased as the Commonwealth became more involved in a field previously entirely the responsibility of the states. In the 1950s and 1960s this involvement was motivated by the belief that the role of government was to organise the conditions in which individuals could act responsibly by developing the virtues of thrift and self-help, while at the same time providing assistance for the permanently poor, especially ‘the aged’.42 As Jill Roe notes, the relatively easy prosperity that characterised the postwar economy in Australia, gave no cause for the mindset that underpinned the greater involvement of the federal government, one that rejected state intervention into social life, to acknowledge these cumulative changes as such.43 At the same time the extent of the financial commitment provided visible proof of ‘the aged’ as an inexorably increasing financial burden on the community.
What role did medical practitioners play in the emergence of this field of activity related to old age? On occasions such as the Geriatrics
Warnhurst, Hale & Iremonger, Sydney, 1995. The existence of poverty amongst age pensioners, despite these measures, was demonstrated in the 1960s survey conducted by researchers at the Institute of Applied Economic and Social Research at the University of Melbourne, R.F. Henderson, A. Harcourt, R.J.A. Harper, People in Poverty: A Melbourne Survey with Supplement, Reprint 3, Cheshire, Melbourne, 1975. 42 The proposal to grant subsidies for purpose built housing for elderly people was first mentioned in a policy speech by Robert Menzies, leader of the Liberal Party, at the 1954 election. There was no clear constitutional basis for the measure, Kewley, op. cit. p.315- 316. The subsidy was intended to enable old people to preserve a domestic environment at a time when age or depleted resources imposed obstacles to their capacity to do so. It was a measure that was consistent with the ‘ “home-centred independent individualism”’ characteristic of much of the legislation in the 1950s, J. Murphy, Imaging the Fifties, Private Sentiment & Political Culture in Menzies’ Australia, Pluto Press, University of New South Wales, Sydney, 2000, p.14. Few impoverished old people benefited from the measure because the voluntary bodies that made use of the subsidies provided through the Old Persons Homes Act, required residents to make an ingoing payment, Kewley, op. cit. p.323. 43 J. Roe, ‘Perspectives on the Present Day: A Postscript’, in Roe, 1976, op. cit. p.314-315.
214 Conferences when many of the participants in this field gathered together, medical practitioners were prominent in every respect. They were a majority amongst the speakers and the constant reiteration of the theme of the ‘Geriatric Service’, by both local and visiting speakers, reinforced the emphasis on a medical model in the provision of services for old people whose independence was diminished. However, when account is taken of the failure of the geriatric service to be accepted as the principal means of providing hospital and medical services for this group, the apparent prominence of these practitioners takes on a different complexion. Constant repetition of the theme of the ‘Geriatric Service’ at the geriatrics conferences throughout the 1960s, in the face of its very limited development, can only be viewed as a lesson that went unheard by the various parties who sat and listened to it - the voluntary agencies and community associations that were busy expanding institutions, and even the government departments in charge of overseeing the provision of hospital and welfare services in the state. The absence of the private nursing home industry at these conferences testifies to the peripheral position of the medical advocates of the geriatric service in relation to the overall provision of services for elderly people.
Even in promoting the provision of community-based services to minimise the need for institutional care, the advocates of the geriatric service were in danger of being sidelined. The expansion and multiplication of welfare organisations throughout the 1960s expanded the field of work for social workers. From the 1950s, whether in voluntary agencies, local government or state government departments, social workers began to establish their expertise in relation to the elderly in addition to their existing work with children, adolescents and other adults.44 Social workers appear to have taken a lead in itemising and publicising the deficiencies in nursing home provision for infirm old people. In the
44 In Melbourne the Citizens’ Welfare Service appointed Shirley Ramsay, as the first social worker to be given special responsibility for aged people. Her next position was with the Victorian Old People’s Welfare Council, and after that, she took a position with Nunawading Council, also with responsibility for elderly citizens, Personal communication from S. Ramsay, 30/9/97. See also, E.P. Dobbyn, ‘The Contribution of the Social Worker to Care of the Aged in General Practice’, Annals of General Practice, xvii, part 4, pp.169- 171. At the time Dobbyn held the position of Senior Social Worker in the Division of Geriatrics, Queensland Department of Public Health, see Jones, 1980, op. cit. for an interpretation of why social workers, despite the more favourable funding environment of the 1970s, were unable to establish a role in the provision of personal services, p289ff,
215 Geriatrics Conferences it was a social worker, Marie Coleman, who took on this task in a paper read at the 1969 Conference. In Victoria, hospital social workers conducted surveys, first in the mid 1960s, and then ten years later, to illustrate the problems of an unregulated provision of nursing home beds.45
There was common ground between the social workers and nascent rehabilitationists and geriatricians, in that both wanted to minimise the provision of institutional care, to give elderly people some choice in the matter of where they lived once their independence was compromised. However, in their focus on the community, social workers were more closely aligned to the shift that occurred in the 1960s towards the provision of community services. It was a shift that Maureen Bowman describes as the ‘mood of the sixties’ – a ‘generalised reaction against large centralised systems, in favour of small units and community-based services.’46 To the extent that this reaction was also against the medicalisation of social problems, social workers were more in tune with this climate of thought than the medical practitioners who wanted to establish geriatric services that included a domiciliary service component.47 The problems posed by this change in the culture of ‘welfare’ for doctors wishing to promote geriatric medicine, became clearer in the 1970s when the shift to non-medical ‘community care’ in both health and welfare services, was underpinned by federal government funding. If the Australian Geriatrics Society promoted the hospital component of geriatric services, it risked isolating geriatrics by appearing
45 M. Coleman, ‘The Pattern of Permanent Care for the Aged’, Geriatrics Conference, 1969, pp.47-57, Geriatrics Conference, 1966-76, op. cit.; E. Marshall, ‘The Chronically Ill- A Survey’, a Report from the Nursing Homes Group of the Victorian Association of Social Workers, August, 1975. 46 In Britain the promotion of a role for social workers in providing personal services, working towards establishing an environment conducive to ‘social’ well-being, occurred within the same development that promoted the role of ‘community physician’ and that provided inspiration for a revival of social medicine in Australian medicine, Lewis, op. cit. p.105. 47 M. Bowman, ‘The Welfare Officer For the Aged : A Study of the Implementation of a Commonwealth Program’, Occasional Paper in Gerontology, No 8, National Research Institute of Gerontology and Geriatric Medicine, 1985. One obstacle faced by social workers interested in ‘demedicalising’ welfare, was that in Victoria, community based welfare services for the elderly were administered by the Department of Health and a doctor’s (general practitioner’s) certification of need was required before they could be authorised. In these circumstances nascent geriatricians were at as much of a disadvantage as social workers. Not only were the needs of the elderly medicalised without reference to specialist expertise, other potential recipients did not even qualify because a doctor could not attest to the social deprivation that underpinned their needs, Coleman, 1969, op. cit. p.47ff.
216 too much of the ‘medical establishment’ and insufficiently ‘community’- oriented.48
The peripheral standing of the medical advocates of geriatric services was not simply a matter of reluctance on the part of state governments to heed their message. The creation of positions such as Director of Geriatrics in some of the states indicates some preparedness within state bureaucracies to respond. Evidence can also be found in the record of the meeting of state ministers of health in Sydney in 1966. The previous year these ministers passed a resolution that showed the influence of the medical advocates of geriatric services. They called for the provision of services for old people to be based upon an organised body of research in which needs were identified objectively, and for an emphasis on providing services directed towards retaining elderly people at home rather than in institutions. This resolution was discussed again in 1966 and each minister reaffirmed his state’s support. However it was clear that each was wary of committing his government to any course of action, especially one that involved greater expenditure, until it was clear how the federal government would respond. Over the past twelve months there had been no indication from that quarter as to whether the resolution had been accepted or rejected.49
The reluctance of state ministers of health to take any steps without clear direction from the federal government is understandable. On one hand the nursing home subsidy had brought the Commonwealth into an area of expenditure that had previously been left to the states. On the other hand, it was provided as a cash benefit, a form that represented minimal interference in the organisation of services in the states although it went against the spirit of the resolution supported by the health ministers. When the ears of the federal government were finally opened to proposals for the provision of domiciliary services - a result of concern at the increasing expenditure on nursing home subsidies - the effectiveness of
48 Archives Australian Society for Geriatric Medicine, letter dated 5/4/79 from E. Erlich to R. B. Lefroy. 49 Conference of State Health Ministers, Held in Sydney, 19th to 21st April, 1966, Government Printer, Sydney, pp.125-128. Participants in this discussion all stressed the enormity of the ‘problem’, stressing its social and economic and psychological dimensions. This formulation may not have helped the cause of geriatric medicine or geriatric services because it implied the need for action on an extensive front and large expense.
217 the domiciliary and paramedical services promised in legislation introduced by the Gorton government, was diminished in some states by antagonism to such overt intervention in state affairs.50 This legislation, enacted in the States Grants (Home Care) Bill in 1969 was the first indication that Sidney Sax’s definition of geriatrics as a system of ‘community care’ had begun to exert some influence in the construction of the ‘field’ of care for the aged in the federal arena. The extent of this influence was not so great, however, that this form of provision overcame the problems posed by the fragmentation of services.51
Professional Organization Despite their relative isolation and small numbers, the medical practitioners involved in providing or organising services for the infirm aged did establish professional bodies during the 1960s and early 1970s. They did so in such a manner that the differences in ideas about the nature of geriatrics as medical work were accommodated rather than narrowed down. To some extent this was inevitable in view of their low numbers and insecure foothold within the profession as a whole. The overall effect, however, was that the advocates of geriatric medicine were not in a strong enough position to exert any control over the conditions in which the specialty was to develop.
50 States Grants (Home Care) Bill, 1969, Kewley, op. cit. p.484-485. John Gorton, Prime Minister and leader of the Liberal-Country Party Coalition at this time, set up a committee to review social welfare provisions with the aim of ensuring those in need would be helped without discouraging self-reliance, and fostering coordination amongst the various departments involved in providing these services, Kewley, op. cit. p.390. The Victorian government, in this case, was reluctant to take advantage of the funding provided through this legislation, not because of matters related to the actual legislation, but because of concerns regarding state-commonwealth relations, Bowman, op. cit. p.24. Bowman’s study looks at this legislation and how it was implemented by the different states. 51 Bowman, op. cit. p.6-9. The Consultative Committee for the Care of the Aged established by Sax in the early sixties, presented a report to the minister for health in New South Wales outlining the necessary components of community based services to relieve the demand for institutional care. The connection between the 1969 legislation and Sax’s plans is clear from his address to the New South Wales Gerontological Society, Sax 1966, op. cit. He listed a range of ‘domiciliary and supportive services’, noting their relation to social welfare rather than hospital services, then continues, ‘There should be some operational focus within local communities designed to ensure that existing services are accessible … Thought will have to be given to the appointment of executive welfare officers and to the administration and cost of the services’, p.3. While the legislation may have been influenced by Sax’s ideas in one respect at least, as he himself points out it, was quite contrary to his notion of a comprehensive, state-wide program. Funding was made available to local voluntary agencies, thus ensuring a continuation of fragmented services dominated by local interpretations of need, S. Sax, Ageing and Public Policy in Australia, Allen & Unwin, St Leonards, NSW, 1993, p.87.
218 The first association formed by the advocates of the geriatric service was the Australian Association of Gerontology, founded in the mid-1960s. The Association took over from the Victorian Geriatrics Conferences as a meeting place for the various professionals and groups involved in the growing field of ‘care of the aged’, again with the exception of representatives of the private nursing home industry. As my concern is with the emergence of a medical role in relation to old age infirmity, the Association will be considered only from that point of view. None of the possibilities for the role of geriatrician - that is, provider of age-related rehabilitation services or age-related acute care and rehabilitation services, or investigator of common degenerative disease - were uppermost in the mind of David Wallace when he took the first steps to establish an Australian association to be affiliated with the International Association of Gerontology. At the time, in the late 1950s, Wallace had just returned to Greenvale Village to take up his appointment as geriatrician and to develop a geriatric service there. While he was overseas on a study tour he attended the Fourth Congress of the International Association of Gerontology and the President of the Association suggested he set up an Australian branch.
Wallace’s ideas about the form the association should take were clear when, on his return to Melbourne, he wrote to the Vice Chancellors of the Universities of Melbourne and Sydney.52 He wanted to develop the science of gerontology in Australia along lines similar to the British Society for Research on Ageing, rather than the International Association of Gerontology, which, he believed, focused on welfare rather than science.53 His letter to the Vice Chancellor of the University of Sydney led him into correspondence with Arthur Everitt, a physiologist already engaged in studying the ageing process in rats.54 Everitt was out of the
52 Details of Wallace’s efforts are taken from letters written by him to the universities, to Arthur Everitt and to the National Old People’s Welfare Council over a period from mid 1959 to the end of 1960. The letters are held in the archives of the Australian Association of Gerontology, Box File A. 53 The British Society for Research on Ageing was established in 1947 with funding from the Nuffield Foundation, the biological interests cultivated by this group contrasted with the clinical and service oriented interests of the doctors such as Marjory Warren, Trevor Howell, Lionel Cosins and Eric Brooke, who established the British Geriatrics Society in the same year. 54 Everitt’s interest in this matter may have developed under the influence of his associates in the Department of Physiology at the University of Sydney. Professor Frank Cotton had established a gerontological group affiliated with the British Society for Research on
219 country at the time but replied suggesting likely contacts for Wallace. Everitt also enclosed a letter for Wallace to circulate outlining a definition of gerontology. It was a definition which included ‘not only the study of natural age changes in various body functions, metabolism, enzyme activities, histology, response to drugs etc., but also the study of the diseases of old age … and then there is the biology of ageing’.55 Wallace’s own work in the following years was to demonstrate his interest in diseases common in old age and in theories of ageing.56
He had little response from the contacts Everitt had suggested. The only expressions of interest came from the staff of the research laboratory that had been established at Lidcombe Hospital in New South Wales in the early 1960s, and the Department of Psychology at the University of Western Australia.57 His letter to the University of Melbourne led him in a different, and not altogether welcome, direction. It brought him into contact with Professor R. D. Wright, Professor of Physiology and Dean of the Faculty of Medicine. Wright expressed interest in the idea and advised Wallace to make a list of all the charitable organisations interested in old age and then consult him as to the next step. The influence of developments in Britain in relation to Victorian responses to the ‘problem of old age’ has been a recurring theme throughout this study, and it is likely that Wright’s reaction was another, more subtle manifestation of this influence. In 1959 Wright had been back in Melbourne for a couple of years after some time spent in England. In referring Wallace to the
Ageing in 1949. It was disbanded after a few years. ‘Gerontological Activity in Australia’, Newsletter of the Australian Association of Gerontology, vol 1, no 1, 1965, p.2. 55 In a paper calling for the development of experimental gerontology in biological and medical research, at a symposium on gerontology in Melbourne in February 1976, Everitt cited the work of Brailsford Robertson as the first Australian investigation into the ageing process, Multidisciplinary Gerontology: A Structure for Research in Gerontology in a Developed Country, ed I.R. Mackay, S. Karger, Basel, 1977, pp.8-16. Robertson was Professor of Physiology at the University of Adelaide from around 1919 to 1930, his work investigating processes of growth was commemorated in a special edition of The Australian Journal of Experimental Biology and Medical Science, (which he founded) published in 1932, MJA, vol 1, 1919, p.323, vol 1, 1930, p.269, vol 1, 1932, p.691. 56 After leaving Greenvale Wallace worked as a physician in a group practice in Goulbourn, New South Wales where he published an epidemiological study of cerebro- vascular disease in the area, ‘A Study of the Natural History of Cerebral Vascular Disease’ MJA, vol 1, 1967, pp.90-95. He was awarded the Doctorate of Medicine in 1968 at the University of Sydney, for a thesis on the topic, ‘Hereditary Sensory Radicular Neuropathy: A Family Study’, and published ‘The Inevitability of Growing Old’, Journal of Chronic Disease, vol 20, 1967, pp.475-486. 57 The establishment of research facilities at Lidcombe has already been noted above in the outline of developments in New South Wales. Geoffrey Hughes, deputy superintendent at Lidcombe in the early sixties, and Arthur Everitt formed the Gerontological Association of New South Wales in 1962, preceding the national association by three years.
220 charitable organisations he may have been expressing ideas already formed about what gerontology entailed, ideas in which welfare predominated, as a consequence of his second wife’s association with the Nuffield Association in England where she had worked as a research assistant in the mid 1950s.58
The Victorian Old People’s Welfare Council responded with enthusiasm to Wallace’s letter. At the time the Council, together with the New South Wales Council, was in the process of setting up a national body. Their aim was to establish a more straightforward communication with the federal government, and to ensure the coordination of age-related activities, and the promotion of research into the problems of old age on a national scale. The formation of the national body coincided perfectly with the appearance of a task so suited to the Council’s ambition to play a leading role in encouraging the development of interest in ageing at all levels. But Wallace had misgivings about this line of development. Writing to Everitt he cautioned against allowing a ‘non-scientific’ body to play a prominent part in the early development of a scientific organisation. The organisation would be suffocated before it ‘could take a breath’. It should be, from the start, ‘a body capable of furthering in a concrete manner the conduct of basic research into the ageing process. … if it seemed to be tending towards the welfare association pattern I should want no part of it.’59
In the event, his misgivings about the leading role taken by the National Old People’s Welfare Council must have been set aside. At the inaugural meeting of the Australian Association of Gerontology on the 10th June 1964, at the John Curtin School of Medical Research, at the Australian National University, Wallace was elected to the position of honorary secretary/treasurer. Perhaps the preponderance of medical men in the Council of the new association, and the absence of a representative of the National Old People’s Welfare Council, allayed his apprehensions.
58 P. McPhee, ‘Pansy’, A Life of Roy Douglas Wright, Melbourne University Press, Carlton South, Victoria, 1999, p.109. Meriel Wilmot’s association with the cause of the aged continued after her return to Melbourne. In 1983 the Australian Council on the Ageing established a library in its Victorian headquarters, named the Meriel Wilmot Library in recognition of her 21 years of service to the needs of old people as secretary to the Myer Foundation, Victoria. 59 Letter from Wallace to Everitt, 26/11/60.
221 However none of the medical representatives, with the exception of Wallace and Everitt, had, in their public discussion of the topic of old age, nominated the scientific study of the ageing process as a priority. In time branch associations were formed in the states; New South Wales had already formed a Gerontological Society in 1962 and it affiliated with the national body. The National Old People’s Welfare Council, having carried out its self-appointed task of sponsoring the formation of the Association, retired from the limelight having provided sufficient funds to meet initial expenses and the early operating costs of the Association.60 The composition of the governing body of the Association reflected the leading role taken in this field by medical practitioners – eight out of the ten members of the first Council were medical men and two were female social workers.61
The Association’s objectives included the promotion of gerontological research, encouragement of cooperation between organisations and individuals interested in gerontology and the promotion of training for persons in all fields of gerontology.62 A glance at the programs of the annual conferences that began in 1965 shows that many of the individuals who participated in the Geriatrics Conferences in Victoria adopted the Australian Association of Gerontology as a professional body. Similar themes may also be noted: the geriatric service as the model of hospital and medical services for infirm old people, discussions of the ‘needs’ of the aged, the organisation and management of institutions and, a perennial focus of interest in relation to old age, retirement.63
David Wallace’s hope that the Association would encourage a form of gerontology that did not focus on welfare was partially realised in the presentation of papers on the topics relating to degenerative disease and the scientific understanding of the ageing process. These occasional
60 Minutes of Inaugural Meeting of the Australian Association of Gerontology, 10/6/1964. Mr James Ross, benefactor of Mount Royal, whose contribution made possible one of the travelling scholarships awarded to three of the first doctors appointed as geriatricians in Victoria, once again contributed to the cause of ‘old age’ by donating to these funds. 61 For a list of members of first Council see Appendix 2. The second issue of the Association’s Newsletter listed 68 individual members of whom around 40 were members of the medical profession in private and hospital practice and the state bureaucracies. 62 Proceedings of the Australian Association of Gerontology, vol 2, no 1, Contents page. 63 See C. Russell, ‘Aging as a Feminist Issue’, Gender Studies International Forum, vol 10, no 2, pp.125-132 on the topic of retirement as an ‘andro-centrist’ concern which represents the ‘real’ issues of ageing as those that concern men.
222 papers did not, however, represent any institutional developments based on a study of ageing or indeed a clearly identified clinical concern with health and sickness in old people. It was rather, that amongst the general run of work of these individuals, there was some aspect related to old age. The AAG conferences were not the principal forum for the dissemination of studies in the fields of endocrinology, general medicine or biological research.64 The form of gerontology that was fostered by the Australian Association of Gerontology may be discerned in the collection of papers given at a symposium organised by the New South Wales Division of ANZAAS. Introducing this collection Sidney Sax, as inaugural president of the Australian Association of Gerontology, noted that one of the functions of ANZAAS was to bring to public attention current needs for research. The papers published in support of the need for research relating to old age suggest that research would take the form of an analysis of dependency amongst the aged, its demographic representation and significance in the economy of the nation and the provision of services. The purpose of such studies was, hopefully, to inform government policy.65
While the Australian Association of Gerontology provided a national forum for doctors interested in matters relating to health and illness in old age, its potential for supporting the development of any particular organisation of medical work around this topic was limited for a number of reasons. First, it was not entirely a medical association despite the predominance of medical practitioners amongst its members, nor is there any indication that it was ever intended to be one. Second, as is already clear from the foregoing survey of the medical roles that were emerging in relation to old age infirmity throughout the country, the practitioners involved had different objectives within the larger project of ensuring the provision of appropriate hospital, medical and welfare for a neglected segment of the population. Bruce Ford, promoted this objective within the broader framework of medical rehabilitation. Sidney Sax’s concern, as public health administrator, was with the coordinated provision of
64 For example the programs of the 1972 and 1974 conferences, Proceedings of the Australian Association of Gerontology, vol 1-2, 1969-1976. 65 S. Sax, ‘Editorial Preface’, in The Aged in Australian Society, ed S. Sax, Angus and Robertson, 1970, p.1.
223 community based welfare services.66 David Wallace supported research into the process of ageing on one hand, and the ordinary ailments of ageing individuals on the other. R. B. Lefroy envisaged the geriatrician’s role as provider of medical services including care during acute episodes of sickness and advice and assistance to the general practitioner in the community, as the community physician.67 In the late 1960s another voice entered the discussion, Gary Andrews, Medical Superintendent at Lidcombe State Hospital in New South Wales, saw the role of the consultant physician in geriatric medicine as supervising a hospital unit within a regional system of services which provided ‘comprehensive and modern facilities for medical investigation and treatment modified to be appropriate to the needs of elderly and disabled patients’, in addition to ‘retraining’ facilities.68 Although all, in one way or another, supported the introduction of the geriatric service as the most appropriate form of hospital service for old people at risk of needing custodial care, their diversity of views meant that the AAG could not work to promote a specific field of medical expertise in the same way that similar groups had supported other medical specialties. The common denominator of interests within the AAG was the provision of particular age-specific services – not a specific medical field of expertise.
A further impediment to the AAG acting as a basis for establishing a specialist field of medical work, or indeed work in any of the fields represented in its membership, was its complete separation from any research, teaching or accreditation body. The professional interests that were found in the Association developed through the relevant professional bodies, not the Association. By the early 1970s the medical advocates of the geriatric service had formed their own more narrowly focused
66 S. Sax, ‘Chronic Disabilities as a Public Health Problem’, MJA, vol 2, 1968, Supplement, Report of Australasian Medical Congress. 67 Lefroy’s use of this term is discussed below. 68 G. Andrews, ‘Planning a Geriatric Service’, Proceedings Australian Association of Gerontology, vol 1, 1971, pp.149-154. Andrews had gone to Glasgow to do his physician training with W. F. Anderson (Sir William) following a visit by Anderson to Australia in 1968. He returned to Lidcombe to the position of medical superintendent. During this 1968 visit Anderson attended the Geriatrics Conference and a seminar at Lidcombe Hospital where he spoke on the topic of training the geriatrician physician, Newsletter of the Australian Association of Gerontology, vol 1, no 8, 1969, p.67. Andrews, with D. H. Blake, an English physician and medical superintendent at Bendigo Home and Hospital for the Aged in 1968, were, it appears, the first physician geriatricians in Australia who trained with Anderson, see Chapter Six, Personal communication from D. H. Blake; The Australian Medical Directory; Sir William Ferguson Anderson, ‘Geriatrics’, op. cit.
224 professional groups. The Society for Physical Medicine and Rehabilitation, formed in the 1940s with Rehabilitation added to its name in the 1950s, was, by then, in the process of seeking approval of their training program from the Royal Australasian College of Physicians. Up to this point the Diploma program developed by the Association, had been supervised by the Australian Postgraduate Federation in Medicine.69 In October, 1972 in Melbourne - a surprising location in view of the apparent lack of medical interest there, in geriatrics as a specific form of medical work - the Australian Geriatrics Society was formed, despite some debate as to whether such a society was necessary.70 In keeping with the second objective of the Society, ‘to promote, improve and encourage training to the highest possible level’, one of the earliest tasks was to seek recognition from the Royal Australasian College of Physicians that special training was needed for physicians to practice geriatric medicine.71 Potential problems arising from differences about what constituted geriatric medicine and where it could be practised, were circumvented by the structure of the core component of the training program that was eventually accepted by the College in 1975.72
The following month an editorial in the Medical Journal of Australia provided a formal definition of the geriatrician’s work. The anonymous author described the existing situation in Australia where ‘without proper assessment and without any attempt having been made at rehabilitation’, patients are admitted directly to permanent institutional care. This was compared with the situation found by Marjory Warren when she first encountered the inmates of the Poor Law Infirmary attached to the West Middlesex Hospital in London in the late 1930s. The geriatrician’s role
69 Wedlick, 1957, op. cit. p.718. The specialty was slow to develop in England in the interwar years, but gained some impetus from the wartime emphasis on rehabilitation, Stevens, 1966, op. cit. p.47; Cooter, op. cit. p.227. 70 Gary Andrews, medical superintendent of Lidcombe Hospital was the first president of the Society. Not all of the medical practitioners involved in providing geriatric services were in favour of a special medical society, believing that the Australian Association of Gerontology provided sufficient forum for doctors interested in geriatric medicine, R.B. Lefroy, 1988, op. cit. p.69. 71 Ibid. 72 The need to accommodate variation arose from the differences in organisation in the various states, and in the training and experience of practitioners – not all of who would qualify, or even wish to qualify for College Membership. In view of their relatively small numbers, the promoters of geriatric medicine could not afford to be too restrictive. Material sent by the Australian Geriatrics Society to the National Specialist Qualification Advisory Committee indicates that core training consisted of twelve months ‘in an
225 was to introduce a form of medical care aimed at preserving independence, not to encourage dependence. The author combined the various possibilities for geriatric medicine, describing the special skills of the geriatrician physician in relation to, ‘… the clinical, social, preventive and remedial aspects of illness in the elderly’.73 The jurisdiction envisaged for this role was regional, with the geriatrician’s responsibilities extended from the provision of services within a hospital setting, to long-term care, and community based services. Curiously, in view of the use of population statistics showing growing numbers of elderly Australians that substantiated the need for an age-related medical specialty, the advocates of geriatric medicine also claimed responsibility for all the disabled, a claim that brought them into conflict with medical rehabilitationists.74
A further sign of an emerging community of ‘geriatricians’, and its rather fragile condition, was the appearance of the Journal of Geriatrics in 1970.75 Affiliated with other world-wide publications and, if the advertisements are any indication, funded by commercial interests, it was described as a journal devoted ‘to the science and practice of geriatric medicine’. At first there were six issues annually, later ten. The editorial board included most of the names that have been prominent in the chapters of this study, with the addition of others, many of them associated with state government posts. The volumes published between 1970 and 1972 contained local and international material but by April 1973, the Editor was calling for more local articles, a ‘greater scientific expression of local experience and expertise’. The call went unheeded it appears, as a year later the material in the Journal was entirely foreign and the last edition appeared in 1975.
approved post which provides experience in Geriatric Medicine, Rehabilitation, General Medicine, Community Care …’, Archives Australian Society for Geriatric Medicine. 73 ‘Geriatric Medicine’, MJA, vol 2, 1972, p.1041-1042. 74 Undated draft of the statement sent by the Australian Geriatrics Society to the National Specialist Qualification Advisory Committee in support of its call for recognition as a field of specialist medical work, Archives of the Australian Society for Geriatric Medicine; ‘Medical Rehabilitation’, MJA, vol 1, 1974, p.907-908. 75 Published by the Geriatrics Publishing Company of North Sydney between 1970 and 1975, in 6 volumes. Affiliated publications included Modern Medicine of Australia, Modern Medicine USA, Modern Medicine Great Britain, etc.
226 Professional Integration By early 1973, only months after the Australian Geriatrics Society was established, the question of what form geriatric medicine would take was still open. Many of the first members of the Society were general practitioners working in state hospitals, and like most Victorian ‘geriatricians’, satisfied with their standing as such. Only a few of these early members qualified for membership of the Royal Australasian College of Physicians or one of the British Colleges. The early move to gain acceptance of geriatric medicine by the RACP, suggests that at least there was the intention that, in future geriatric medicine would be practised by College-accredited physicians.
However, the broad definition of the role of the geriatrician and the inclusion of administrative, social and clinical elements ensured that it was a role that lay outside the usual conception of the physician’s work. Geriatric medicine was further differentiated from the work of physicians in that the relationship between geriatric medicine and the state was more explicit than it was in the case of those physicians whose work was confined to hospitals and private practice. Medical rehabilitationists were also in this position. By defining geriatric medicine as a form of practice linked to regional hospital services and dependent upon the activities of other health professionals, such as social workers and therapists, nascent geriatricians made their close alliance with the state much clearer than did their other physician colleagues. The dependence of the latter upon the state was concealed in the emphasis in the existing organisation of medical work, on fee-for-service, personal curative medical services that supported by public funds in the form of research grants, subsidies for hospital services and private hospital and medical insurance.
By the late 1960s the shortcomings of the organisation and funding of hospital and medical services in Australia had become the focus of critical attention which, for the first time, was formulated in terms the Federal government could not easily ignore. Academic researchers provided material for a well-informed critique of the existing system for providing and organising hospital and medical services, and in 1968 the Gorton government responded by establishing an independent enquiry into the
227 hospital and medical insurance scheme.76 The provision of welfare was also subjected to a similarly well informed critique.77 Within the medical profession a range of matters were discussed. Once again general practitioners expressed concerns about their exclusion from hospitals and the expansion of specialist services, concerns that were aggravated when the government implemented one of the recommendations of the Nimmo committee that differential insurance benefits be paid for specialist services.78 Others – general practitioners and medical educators – were concerned about the capacity of medical education and the organisation of services to equip doctors to meet the demands posed by the forms of disease and disability that were prominent in the Australian community. In 1965 the Royal Australian College of General Practitioners commissioned one of its members to undertake a survey of general practice to clarify these problems and in 1968 medical educators, researchers and practitioners gathered in Canberra at the John Curtin School of Medical Research to discuss matters relating to medical training and the organisation of medical services.79 At this conference it was clear that,
76 Kewley, op. cit. p.391. At this time the Senate began to play a part in policy development and assessment through a range of Select Committee enquiries, including one on the cost of hospital and medical care. The Committee of Enquiry commissioned in 1968, was chaired by Mr Justice J.A. Nimmo and it presented its report in March, 1969, Ibid. pp.503-505. 77 Public discussion at this time was stimulated by publication of the survey of people living in poverty in Melbourne, Henderson et al, 1975, op. cit. Other (unpublished) contributions to the discussion were made by the Senate Standing Committee on Social Welfare which existed for a short time between 1968 and 1969, and expert representations were made by the Australian Association of Social Workers, the Victorian Council of Social Service and the Australian Council of Social Service, Kewley, op. cit. p.502-503, and p.377ff. The Institute of Applied Economic and Social Research at the University of Melbourne played a prominent role in providing the research base for discussions of both health and welfare in the 1960s and 1970s. It was founded in the early to mid-1960s by R.I Downing, Ritchie Professor of Economics at the University of Melbourne, Brown, 2001, op. cit. pp.227-231. 78 Provision was made for the payment of differential insurance benefits for specialist medical services to be structured so that the net cost to the patient was nearly identical whether specialist or general practitioner services were involved. National registration of specialists was required with the associated stipulation of training requirements, thus obliging general practitioners to identify themselves as either GPs or specialists. The formalisation of specialist practice further eroded the possibilities for GPs to perform procedures in hospitals and a GP whose income depended mainly on surgical procedures would be particularly hard hit because they were more highly reimbursed than ordinary attendance, R.B. Scotton, Medical Care in Australia, An Economic Diagnosis, Sun Books, Melbourne, 1974, p.83, p.8. This amendment to an insurance scheme that was, initially, intended to protect the position of the general practitioner, raised a storm of protest from a sizeable group of GPs who believed the Australian Medical Association had advanced the interests of specialists above theirs, and the subsequent formation of a small but vocal, break-away group, T. Hunter, ‘Medical Politics: Decline in the Hegemony of the Australian Medical Association?’ Social Science and Medicine, vol 18, no 11, p.974-975. 79 C. Jungfer, ‘General Practice in Australia; A Report on a Survey’, Annals of General Practice, vol x, part 1, 1965, pp.4-48; the proceedings of the 1968 conference were published in Brown & Whyte, 1970, op. cit.
228 once again, Australian medical administrators and educators were looking to social medicine for inspiration in addressing issues related to the funding, organisation and content of medical services.80
In contrast to the earlier period, when Australian doctors had gone to England to imbibe the lessons of social medicine, in the late 1960s social medicine came directly to Australia. Thomas McKeown, who had succeeded John Ryle as the dominant figure in the discipline, came to Australia in 1967-68 and was a principal speaker at the Canberra conference.81 In addition to emphasising the social components of disease, McKeown also devoted attention to the organisational aspects of medical services. He used the concept of a ‘balanced hospital community’ to describe the integration of all forms of hospital and welfare services in the one institution, and directly related to the needs of a specific local population, rather than those of medical research and ‘other ephemeral interests’.82 This aspect of his influence was already evident in the approaches to defining geriatric medicine displayed by Sidney Sax and R.B. Lefroy.83
McKeown’s influence, and that of social medicine in general, was clearly evident the book Sax published in 1972, in which he proposed a form of organisation of health services in Australian conditions so they could better address prominent problems of ill-health in the Australian population.84 The emphasis in this text was on the organisation of medical services outside the hospital, services that, in the Australian setting, were provided principally through general practice.85 The ideas in Sax’s book were given practical form in the Community Health Program, one of the
80 See Chapter Two. 81 Porter, 1977, op. cit. p.102; Brown & Whyte op. cit. Introduction. Rene Dubos was the other notable guest at the conference. McKeown came to be known principally for proposing that changes in social and economic conditions played a greater part in combating disease than advances in medical science see, The Modern Rise of Population, was published, Edward Arnold, London, 1976. 82 T. McKeown, Medicine in Modern Society, George Allen & Unwin Ltd, London, 1965, p.121ff. 83 Both Sax and Lefroy included references to McKeown and Ryle in their mid 1960s attempts to define geriatric medicine, Sax, 1965, op. cit, Lefroy, 1966, op. cit. 84 S. Sax, Medical Care in the Melting Pot, An Australian Review, Angus and Robertson, Sydney, 1972. 85 The influence of McKeown has been noted because of the personal contact between him and doctors like Sidney Sax, who attempted to develop a local form of social medicine. However Sax’s work also makes as much reference to J.N. Morris, a prominent figure in the development of policy in England, relating to ‘community medicine’ in the late 1960s’, Lewis, op. cit. p.102ff.
229 first of a number of publicly funded health service initiatives introduced by the Whitlam Labor government when it came to power in late 1972.
The appearance of the word ‘community’ in the language of social medicine was associated with changes noted above whereby academics in the discipline of social medicine in Britain, sought to reform the practice of Public Health medicine as ‘community medicine’ and the Public Health medical officer as the ‘community physician’.86 R.B. Lefroy’s description of the physician geriatrician as ‘community physician’ in his 1966 article, may also have been influenced by these developments because he emphasised management of hospital and community resources in maintaining the health of elderly people and supporting the general practitioner in caring for elderly patients.87 In the English context both academics and ‘community physicians’ had difficulty in defining and integrating this new role with its emphasis on epidemiology and the management and planning of health services, with mainstream medicine. Lewis notes that ‘the specialty was born largely of administrative fiat’, more closely bound to a reorganised health service than to the providers of personal, medical services.88 In the Australian context ‘community medicine’ was adapted to provide an intellectual and organisational orientation for re-building general practice (this was also the goal of J.H.L. Cumpston when he became first Director-General of the Commonwealth Department of Health). In this case the problem of integration was compounded by the long-standing reluctance of the medical profession to be involved in any activity that entailed an open association with government.
McKeown’s ideas were influential in the first attempt to incorporate the geriatric service into mainstream hospital services in Victoria, but the service would not be under the direction of a geriatrician. At the Alfred Hospital, the medical superintendent, Ian Howard, seeking to develop the institution along the lines of McKeown’s ‘balanced hospital community’, appointed Bruce Ford to develop rehabilitation services at Caulfield Hospital, and this included the geriatric unit that had been established in
86 Lewis, op. cit. p.100-101. These changes were also associated with the promotion of the role of the social worker in providing personal care services that was noted above. 87 Lefroy, 1966, op. cit. p.206, and Lewis, op. cit. pp.102-104. 88 Lewis, op. cit. p.101-102.
230 the hospital by Cecil Ashley in the mid 1950s.89 Ford later recorded that it was his sociology degree – a Master’s degree gained through a study of the dependent aged in Canberra - together with his experience in establishing a rehabilitation department at the Canberra hospital that ensured his selection for the task at Caulfield.90 A balanced hospital community was, ideally, one in which, services were organised to respond to patients’ needs rather than the requirements of medical research and other ‘ephemeral interests’. This meant that on one hand hospital services were based on the needs of populations and that hospital services were aligned with community based services in a manner similar to that proposed for the geriatric service. On the other hand, it meant that the one hospital complex included all the subsidiary institutions that had grown up around the acute hospital – chronic hospitals, psychiatric services, and maternity and children’s hospitals, and each area was staffed by the same doctors and nurses. The balanced hospital community provided the organisational setting to enable doctors to ‘know’ about illness in all its complexity, as a social as well as a biological phenonomen.91
To the extent that the ‘balanced hospital community’ provided an organisational basis for including a geriatric service within the acute hospital, the adoption of this approach opened up the possibility for doctors in Victoria to link their activities in the Special Hospitals for the Aged into general hospital services. It may well have been the more advanced organisation of the medical rehabilitationists, and the direction chosen by Bruce Ford in developing his career within this organisation,
89 In May 1972, Dr G.I. Howard, medical superintendent at the Alfred Hospital in Melbourne, addressed the annual general meeting of the Victorian Branch of the Australian Association of Gerontology, describing the introduction at the Alfred, of McKeown’s ‘balanced hospital community’, Personal Papers of Dr John Shepherd. 90 B. Ford, 1996, op. cit. p.112; S. Sax, 1985, op. cit. p.8. 91 McKeown, 1965, op. cit. p.121ff.
231 that led to medical rehabilitation (which included the care of infirm old people) being introduced into the ‘balanced hospital community’ at the Alfred. 92
The Monash Medical Centre, a new outer-suburban complex established in the early 1970s was, it appears, also intended to function along the lines recommended by McKeown.93 The establishment of Monash as a ‘balanced hospital community’ might be expected to provide an opportunity for the doctors who provided geriatric services at the nearby Kingston Centre to incorporate their work with that of the acute hospital. However, not only was there no medical practitioner with the higher qualification necessary for appointment to a hospital position, it may also have been the case that the doctors at Kingston actively resisted taking any such opportunity, being content to remain secluded in their own isolated realm.94
The interest in social medicine amongst a minority in the Victorian medical profession persisted through the 1960s. However, the fragmentation of hospital and welfare provision and the lack of a central controlling body - elements essential to the functioning of a ‘balanced hospital community’ - ensured that the prospects for inserting the role of
92 D.H. Blake, the Glasgow trained physician geriatrician and medical superintendent at Bendigo Home and Hospital for the Aged, was qualified to take on the role given to Bruce Ford. He was appointed by Ford to take charge of the Geriatric Division in Caulfield Rehabilitation Hospital, where he remained for four years. The possibilities for developing the role of the geriatrician in relation to acute care in these circumstances were just as limited as they were at Bendigo because the whole idea of rehabilitation medicine was that it was a post-acute form of medical care. In a rehabilitation hospital there was no scope for Blake to practise as a physician geriatrician providing acute care as he would have been prepared to do by his training, Personal communication, 10/4/2001. 93 A remark made by a participant at the 1968 conference in Canberra indicates that the Monash Medical Centre was established with this model in mind, Brown & Whyte, op. cit. p.222; see also Report to Government of Victoria by Hospitals and Charities Commission and Monash University, 1970 which notes that the hospital was intended to provide comprehensive services, including obstetrics, paediatrics, geriatrics and mental health, in addition to medicine and surgery. It was also intended that general practitioners would be included in the hospital medical staff. 94 This inference is drawn from a comment made by Lloyd Jago in the course of an interview for an oral history of the Kingston Centre. Jago was appointed medical officer at Kingston in 1973 and medical superintendent in 1981, and he is noted as saying, ‘For many years we all thought that being a separate isolated identity was a good idea’, Transcript Oral History of Kingston Centre, Ref 21/93.
232 the geriatrician into the acute hospital system remained poor. Even in relation to the Alfred Hospital, the establishment of a rehabilitation service at the Caulfield Hospital, an outlying section of the Alfred did not constitute a balanced hospital community in McKeown’s terms as Caulfield had its own management, and its own medical and nursing staff. And yet it would be because of Sidney Sax’s influence and his promotion of social medicine in the form of ‘community medicine’ that Victorian ‘geriatricians’ were able to shift the focus of their work from the supervision of institutions to the provision of services. How this was done will be addressed in the following chapter. The concern here is to clarify just what form this influence took, and to identify the implications of the association with community medicine for the development of geriatric medicine.
Sax’s influence was pivotal. His capacity for leadership included the ability to present ideas originally developed to suit other countries, so they were more suited to local conditions. This quality was amply illustrated in Medical Care in the Melting Pot.95 His work brought a degree of sophistication to the formulation of proposals relating to health services that had not previously been apparent in Australia. However his personal qualities would probably not have flourished in the way they did under the circumstances in which hospital and medical services were organised in Victoria. It was the recognition in the New South Wales government that health services warranted significant attention in terms of both policy and funding that permitted Sax to implement his ideas.96
Sax and the other advocates of community medicine received a sympathetic reception from the federal Labor government that came to power at the end of 1972, after twenty-three years in opposition. The change of government brought about a shift in thinking in relation to the role of the federal government in the provision of health services and an explicit commitment to expand the role of the public sector in funding and
95 Sax, 1972, op. cit. 96 For example the paper Sax read at the Australian Medical Congress in Perth in 1968, ‘Chronic “Disabilities as a Public Health Problem’ was based on a survey of chronic illness and injuries conducted by the Council of Social Service of New South Wales. The legislation introduced by the Gorton government noted earlier in this chapter, was also based on recommendations by the Consultative Committee for Care of the Aged in NSW and supported by the Minister for Health at the time.
233 providing such services.97 The establishment of the National Hospitals and Health Services Commission, with Sidney Sax as Chairman, for the purpose of developing and implementing health policy, and the Health Insurance Commission to administer a universal health insurance program (Medibank), provided conditions long sought after by Sax’s predecessors, the national hygienists who established the Commonwealth Department of Health in 1921.98
The administrative measures introduced by the Whitlam government opened up the possibility, for the first time at a national level, of establishing a model of health services focused on needs objectively determined in the community rather than the narrowly defined notions of sickness found in hospitals and medical research institutes.99 These measures included funding, not only for comprehensive community based health services but also for the research necessary to identify these needs and to evaluate the effectiveness of services, research not promoted by the National Health and Medical Research Council since the period immediately following its establishment.100 Further, they measures promoted publicly funded health services that combined the contributions of a number of health professionals operating outside the hospital, with an emphasis on prevention and rehabilitation.
What did these changes mean for the small group of doctors who wanted to develop geriatric medicine as a specialist field? Most importantly they opened up avenues of funding health services that were appropriate for the geriatric service, thus providing the opportunity to shift the provision of services out of the field of ‘care of the aged’ into the realm of ‘medical services’. However, even as these opportunities were opened up, they were also restricted. First, the antagonistic reception given the changes
97 R. B. Scotton & H. Ferber, eds, Public Expenditures and Social Policy in Australia, Vol 1, The Whitlam years, 1972-1975, Longman Cheshire for the Institute of Applied Economic and Social Research, University of Melbourne, 1978, p.98ff. 98 Cumpston, 1978, op. cit. p.46-47, p.68. 99 The continuing emphasis on the provision of hospitals diminished the innovative character of these reforms. For another Labor view on the topic of health services see M.H. Cass, A National health Scheme for Labour, Victorian Fabian Society Pamphlet, 9, 1964. 100 The Community Health Program had two major policy objectives ‘(i) to emphasise the neglected aspects of prevention, health maintenance, rehabilitation and primary care; and (ii) to improve the availability and accessibility of health services outside of hospitals and nursing homes’, S. Sax, ‘Australian Health Services – Development and Problems’, Public Administration, vol xxxiv, no 3, 1975, p.222, p.224.
234 introduced under the Whitlam government by the mainstream medical profession ensured that any field of medicine that was promoted within these changes would remain on the margins of medical practice, at least for the short term.
Second, even the changes in health service funding that made possible the development of the geriatrician’s field of practice, also limited them, a situation that may be read as a sign of the peripheral position of the advocates of geriatric medicine within the new order. The first limitation arose out of the location of support for geriatric services within the Community Medicine Program – a program principally directed towards reviving the role of the general practitioner. To the extent that the role of geriatrician had been promoted in the 1960s as adviser to the general practitioner this was a rational arrangement. It certainly fostered the development of ‘skilled full-time assessment and rehabilitation services, and of the well-organised, reliable and comprehensive supportive services ….in every locality’, so vital to the efficient operation of a geriatric service.101 However it did nothing to address the desire of would-be geriatricians to establish hospital-based services to provide appropriate clinical care for acutely sick old people. The limitations of this approach in developing the clinical skills appropriate for the care of elderly people at risk of needing custodial care were highlighted by Eric Saint in his subsequent review of the Departments of Community Health that were established to educate medical students in the field of general practice.102
To the extent that any of the components of geriatric medicine were aligned with hospital-based work, they were included as a sub-section of the broader activity of ‘medical rehabilitation’. In the report submitted by the Interim Committee of the Hospitals and Health Services Commission in November 1973, the word ‘geriatrics’ was used to describe a special group of problems that would be addressed through the provision of hospital-based medical rehabilitation services.103 In its Report on Hospital
101 Ibid. p.225. 102 E.G. Saint, ‘Evaluative Studies Program, Community Practice in Australian Medical Schools’, Australian Government Publishing Services, Canberra, 1981, p.74. 103 Report from the Hospitals and Health Services Commission: Interim Committee, A Medical Rehabilitation Program for Australia, Government Printer of Australia, November, 1973, p.3. Medical rehabilitation was represented on the Interim Committee by Bruce Ford, there was no representative of geriatric medicine.
235 services throughout Australia the Commission reinforced the identification between geriatrics and rehabilitation in its section on nursing homes, recommending the provision of a ‘geriatric assessment and rehabilitation unit’ in every region.104 This subsidiary relationship with medical rehabilitation was also made clear in the Report submitted to the Universities Commission by the Working Party on Rehabilitation Medicine and Geriatrics in 1976. Although the objective of this group was to specify how doctors should be trained to work in the rehabilitation services that the Hospitals and Health Services Commission promoted, there was no representative of the Australian Geriatric Society amongst them. Geriatrics appeared as a small sub-section of medical rehabilitation.105 Conclusion While many opportunities opened up for medical practitioners to develop the practice of geriatric medicine in the early 1970s, they were opportunities lodged within agendas set by others. Most importantly the agenda of the acute hospital remained untouched by the establishment of a ‘post-acute’ field of medical practice to deal with the problems of illness that were not satisfactorily dealt with in the acute field. To the extent that the advocates of geriatric medicine identified problems in the provision of acute medical care for old people at risk of needing custodial care, they gained no advantage under this new regime. The introduction of social medicine into Australian medical practice did not lead to a publicly recognised voice for geriatric medicine.
The position of the advocates of geriatric medicine was not improved in relation to the overall activity in ‘care of the aged’. Not only did the new emphasis on ‘community’ work against extending a medical role into supervising the provision of domiciliary services but the Hospitals and Health Services Commission could not take any action to implement the
104 Report on Hospitals in Australia, Hospitals and Health Services Commission, Australian Government Publishing Service, 1974, p.44. 105 Report of the Working Party on Rehabilitation Medicine and Geriatrics to the Universities Commission, ‘Rehabilitation Medicine and Geriatrics’, Australian Government Publishing Service, Canberra, February, 1976, p.12-13. Members of this committee were, Professor E.O. Hall, consultant to the Universities Commission, Dr G.G. Miller, from the Repatriation General Hospital in Brisbane and Dr. I.W. Webster, formerly of the Department of Repatriation and Compensation and appointed Professor of Community Medicine at the University of New South Wales, in January 1976.
236 regulatory practices it recommended in relation to nursing homes.106 Neither the Commission, nor the federal government, could exert any meaningful control over what was ultimately a matter for state regulation in the same manner that private hospitals were regulated in their activities.107 General practitioners also resented any moves that might promote a specialist medical role in relation to the infirm aged. The uncompromising response to the system introduced prior to the change of government in 1972, indicates little sympathy for the notion that specialist expertise was required in the care of the infirm aged.108 As a means of controlling admissions and costs, a system was introduced whereby Commonwealth Health Department medical officers had to approve the admission of any patient into a nursing home if that patient was to be eligible for Commonwealth subsidies.109 This move, unrelated to the promotion of the role of physician geriatrician, was greeted as ‘a threat to the civil liberties of patients because it could lead to bureaucratic infringement of (their) … rights … to receive the treatment their doctor recommends.’110 The defensive stridency of this response, and indeed of other AMA responses to the innovations introduced in the Community Health Program, silenced the calmer tones of the promoters of geriatric medicine as they reasonably pointed out the need for expert medical assessment before admission to a nursing home.111
106 Report of the Hospital and Health Services Commission, 1974, op. cit. Chapter 4. 107 Kewley, op. cit. summarises the problems facing any attempt at regulation, pp.536-546. The Labor government sought to deal with the problem of an apparent shortage of nursing home beds, and the need to monitor costs, by introducing the deficit funding of nursing homes operated by non-profit bodies, in 1974, Scotton & Ferber, op. cit. p.248 108 Journal of Geriatrics, vol 4, April, 1973. 109 Report from the House of Representatives Standing Committee on Expenditure, In a Home or At Home, (Chairman L. McLeay) October, 1982, p.16. 110 A.M.A. (Victorian Branch) Monthly Paper, No 116, 1973. 111 Editorial, The Journal of Geriatrics, April, 1973.
237 CHAPTER 6 PERCEIVING THE ‘SICK MAN’ IN THE OLD PERSON IN TROUBLE1
Introduction This chapter examines how, in a new climate of federal funding for hospital services, doctors in Victoria were able to shift the focus of their work, away from the management of institutions, towards the provision of services. In doing so it draws together themes that have been present in earlier chapters. These include; state/federal relations, the development of a medical model for dealing with sicknesses that did not respond to individualised, curative medical services, relations between the medical profession and government at all levels and the emergence of a field of welfare provision related to old age.
The funding for innovative health services introduced by the Whitlam Labor government between 1972 and 1975, facilitated the development of the role of ‘geriatrician’ in Victoria. For analysts of federal government policy this brief period stands out as one in which, for the first time, spending on social welfare was not subordinated to that aimed at fostering economic development. This shift in policy brought a change in the fiscal balance between the states and the federal government as the latter played a larger role in funding health and education.2 For analysts of the politics of health provision, this period saw the relative decline of ‘medical monopolists’ and the rise of the ‘equal health advocates’ and ‘corporate rationalisers’.3
The advocates of geriatric medicine sat somewhat uneasily in this company. In promoting the needs of a neglected group of old people they
1 This chapter heading is taken from a lecture given by Derek Prinsley shortly after he arrived in Melbourne in mid-1976, to take up his position as Foundation Professor of Geriatric Medicine and Gerontology and Director of the Mount Royal National Research Institute for Gerontology and Geriatric Medicine. 2 R.B. Scotton, ‘Public Expenditures and Social Policy’, in Scotton & Ferber, 1978, op. cit.p.15ff. 3 H. Gardner, ‘Interest Groups and the Political Process’, in The Politics of Health, The Australian Experience, 2nd edn, ed, H. Gardner, Churchill Livingstone, Melbourne, 1995, p.203-4.
238 had common interests with the equal health advocates. However in emphasising the provision of hospital-based services and an extension of medical practice, the Australian Geriatrics Society was out of step with the trend to promote community-based health centres and non-medical providers of health services. Furthermore, the neglect of old people in existing hospital provisions could not be demonstrated so readily as the neglect of Aborigines or migrants, and it was obscured by the extensive expenditure on nursing home care and other forms of accommodation. In relation to the ‘corporate rationalisers’, a group that must include the advocates of medical rehabilitation because of their promotion of a ‘total service organization’ to meet the needs of the ‘handicapped population’, the promoters of geriatric medicine were in a subordinate position, providing services for a sub-section of this population.4 Finally, despite the universalist emphasis in policies promoted by the Whitlam government, the politics of implementation ensured that the ‘ageing enterprise’ in existence when it came to power remained untouched. Programs inherited from Coalition governments continued unabated.5
The Hospitals and Charities Commission in Victoria took advantage of funding provided through the Community Health Program to develop geriatric services. As was the case in the 1950s, when it was introduced, the role of ‘geriatrician’ was revived because the Hospitals and Charities Commission played a leading part in this process, in cooperation with the committees of management of the geriatric hospitals. Once again the medical practitioners involved were dependent upon the support of these two groups. For the first time in Victoria the provision of medical services was justified in the language of social medicine. No doubt social medicine became more respectable in Victorian medical circles because of the rise to prominence in the federal arena of individuals such as Sidney Sax, who promoted this orientation in the provision of health services. However in relation to the revival of the role of geriatrician in Victoria, social medicine referred not to the ‘social biology’ of old age, nor to a specific
4 B. Ford, ‘Rehabilitation, The Analysis of a Concept’, MJA, vol 1, 1973, p.909-910. 5 H. Kendig, ‘Ageing, Polities and Politics’ in Grey Polity, Australian Policies for An Ageing Society, eds H.L. Kendig & J. McCallum, Allen & Unwin, Sydney, 1990, p.9-10; C. Estes, The Aging Enterprise, Jossey-Bass Publishers, San Francisco, 1981, Estes uses the term ‘aging enterprise’ to call attention to her argument that the implementation of public policy regarding ‘the aged’ leads to the development of entrenched interests that are
239 medical interpretation of disease in old age, but to the development of services to maintain dependent, elderly patients as functioning members of the Victorian community.
Call for the Geriatrician The second attempt on the part of the Hospitals and Charities Commission (HCC) to introduce age-related medical services took place in the early 1970s in a context that had changed significantly since the first attempt in the 1950s, although not in the way that John Lindell had hoped in 1954 when he announced the introduction of geriatric services. Then the introduction of the role of ‘geriatrician’ and the provision of rehabilitation treatment in ‘geriatric services’ attached to the benevolent institutions, was one aspect of a two-pronged response to the demand in the Victorian community for accommodation for the chronically ill and the infirm aged. The other aspect was the provision of funding by the State government to establish such accommodation in the benevolent institutions, demand for which it was hoped, would be minimised by the provision of rehabilitation treatment. By the early 1970s it was clear that this latter aim had not been realised. Instead hospital accommodation had expanded, largely on the basis of the subsidy for long-term care provided by the Federal government; the ‘nursing home’ had emerged as the accepted form of ‘hospital’ care for infirm old people. This provision was found in the Geriatric Hospitals supervised by ‘geriatrician’ medical superintendents, in the voluntary homes and in the converted family homes run as private businesses that proliferated throughout the suburbs following the introduction of the subsidy. The addition of supplementary benefits in the late 1960s, to compensate for the greater needs of some patients, spurred the expansion of the private sector even further.6
At the 1969 Geriatrics Conference, Marie Coleman, described an entrenched response to old age infirmity, centred upon the nursing home. 7
more concerned with maintaining their positions than critically assessing the programs and services they provide, p.2-3. 6 Kewley, op. cit. p.357, ‘intensive care’ was defined as ‘the degree of nursing care or paramedical treatment that the patient needed and received’, and this usually referred to patients who were bed-bound and substantially dependent on nursing care, p.536-537. The addition of the supplementary benefit had the effect of increasing an already significant number of nursing home beds, by 1971 the national number was 3.7 per thousand of population over 65, from 2.3 per thousand in 1963. 7 Coleman, op. cit. 1969, p.49-50.
240 Until the early 1970s, when the Federal government made Health Department authorisation necessary for the purposes of claiming the subsidy, it was the only form of hospital accommodation for no medical opinion of any sort was necessary to secure admission. With the exception of the Geriatric Hospitals and some of the larger voluntary agency institutions that adopted the restorative approach, no consideration was given to the provision of any specific treatment for these patients.8 The common use of the term ‘geriatric’ to describe anything old and decrepit – in particular the nursing home and its inhabitants - was the only indication that community thinking about old age had been influenced by the introduction of the role of ‘geriatrician’ into the benevolent homes, and their subsequent transformation into Special Hospitals for the Aged.9
The ‘nursing home culture’ that had emerged over the preceding decade was associated with the provision of accommodation, and standard of care, of a quality no other sick person was expected to tolerate.10 It engendered an attitude of mind that saw Ellen Newton, a mentally alert woman with limited, but adequate, resources, and susceptible to severe attacks of angina, confined to seeing out her days in a nursing home. Her general practitioner may have taken into account the stress it would have placed on her sister had she returned home, but at the same time there was no consideration of any alternative approach to meeting her needs and she was never consulted. The manner in which the subject was broached by her doctor exemplified the prevailing attitude, ‘“We’ve decided it will be
8 Large voluntary agency homes such as the Royal Freemasons Homes and the Montefiore Homes, adopted the restorative principles developed in the Geriatric Hospitals to the extent that when a training program was introduced for medical staff, these voluntary agency homes were accredited as training institutions, see below this chapter. The introduction of deficit funding for voluntary agency institutions, by the Whitlam government made it possible for them to develop a restorative approach to providing care, A.L. Howe, ‘Report of a Survey of Nursing Homes in Melbourne’, Working Paper no 10, Mount Royal National Research Institute for Gerontology and Geriatric Medicine, 1980, p.25. 9 The term ‘geriatric’ does not appear to have been used generally before the Hospitals and Charities Commission used it to refer to the age-specific services it introduced into the benevolent homes in the late 1950s and early 1960s. 10 Quality of accommodation varied – it included new buildings erected by the voluntary agencies, converted private houses in the private sector, and, in the Geriatric Hospitals, some very old buildings alongside newer ones. In the mid-1970s the Australian Government Social Welfare Commission conducted an inquiry into welfare provisions for old people. Although nursing homes were funded under the National Health Act, the committee did comment on them, concluding that nursing homes were the ‘most unsuccessful as well as the most financially unsatisfactory of the various areas in which the government has provided assistance’ for the aged. It recommended that the nursing home should be part of ‘an integrated system of progressive patient care’, ‘Care of the Aged’, Report of the Australian Government Social Welfare Commission, Chairman, M. Coleman, 1975, Australian Government Publishing Service, pp.127-132.
241 best for you to live in a nursing home ...”’. He continued, as Newton reports: “It will be better if you do not go home,” he says, just like a clerk at a tourist bureau saying you’ll do better travelling in the Aurora, than in the Daylight Express. Home is your particular treasure. For your G.P. it is just another address. You are no longer an average human being, alive with joys and doubts and fears. Hope is not for you either. From today you are a Patient.11
As a ‘patient’ Ellen Newton was a bystander in a process that was to affect the remainder of her life. Her acquiescence illustrates the extent to which those who promoted an alternative approach had failed to penetrate the enclave of the private hospital, personal medical services and the nursing home, which as Sidney Sax observed, was, under the circumstances, assured of patronage.12
Newton was aware also that she was just not any patient, but a ‘geriatric’. She had crossed the boundary separating the twilight world of the ‘geriatric’ from the everyday world. Here the inhabitants no longer played an active part in their own existence and, unless endowed with a robustness of personality that enabled them to resist, the characteristics that had defined them as individuals all their adult lives were obliterated in a deadening institutional regime. Newton’s response betrays some uneasiness in herself at being classified with the inhabitants of this nether world, which itself suggests an aversion similar to that expressed by Horace Tucker’s friends when he went to work at the Cheltenham Old People’s Home in 1965.13 Newton felt sympathy for her fellows in the private nursing home and wondered why they had to be shut up without anything to pass the time, and to accept conditions that, despite the genteel trimmings, made it clear that the enterprise was, above all, a profit making one. At the same time she seems to have taken pains in her account of this period of her life, to emphasise that she could not possibly be regarded as one of them. Her private room, and her efforts to maintain the decencies of a cultivated middle-class existence marked her out as different. Newton’s reaction was not so blunt as that of Tucker’s friends when they
11 E. Newton, This Bed My Centre, McPhee Gribble, Melbourne, 1979, pp.4-11. 12 Sax, 1993, op. cit. p.88. 13 Transcript of interview with H. Tucker, Oral History of Kingston, Ref. 3/93.
242 exclaimed, ‘How could you get mixed up with those dreadful old people?’ but a similar distaste underlies her sympathy – a great repugnance at being a ‘geriatric’.
Despite the age-specific welfare measures that were introduced during the 1950s and 1960s, some of which may have supported Ellen Newton in another form of accommodation, doctors in the public hospitals continued to voice complaints, heard since the late forties, about their problems in discharging infirm old people.14 A medical officer at the Royal Melbourne wrote directly to the Minister for Health, Alan Scanlan, saying that one quarter of the hospital’s beds were occupied by old people who had nowhere else to go, one of whom had been in the hospital for 16 months.15 Social workers took a more positive line, requesting the Hospitals and Charities Commission (HCC) to create the position of placement officer to facilitate the discharge process (a request that, in itself, shows how little the work of geriatricians had penetrated the general hospitals). They also conducted a survey to make the point that it was not simply the absence of nursing home beds that was the cause of these difficulties, but the lack of coordination in their provision and use.16 Pressure on the Commission did not only come from the public hospitals but also from the community, from the families and neighbours who took responsibility for the care of infirm old people. In some of these cases the strain this put on all parties was relieved by intermittent admissions to hospital. Old people who had hospital insurance were in a somewhat better position than those who did not. Admission of an insured patient to a private hospital was much a much easier process than that of the uninsured patient to a public hospital when it was clear to the admissions officer that there could be difficulties in discharging that person. However, private hospital admissions were also interspersed with periods at home to accommodate the requirements of hospital insurance fund regulations relating to length of stay. None of these hospital admissions was for specific treatment: the needs of this group were seen entirely in terms of bed-care.
14 Miss Newton may have been more comfortably accommodated in one of the church run nursing homes, however while they provided extensive accommodation, the nursing home beds were often used only for individuals who were already in the institution, in ambulatory accommodation, a practice that contributed to the apparent shortage of nursing home beds in the 1970s. 15 VPRS 4523/P2/848/9-135. 16 VPRS 4523/P2/848/9-135, and Marshall, 1975, op. cit.
243
It might have been expected that the Geriatrics Division, established in the Commission in the mid 1950s, would have been able to sort out some of these problems, which Divisional officers agreed, arose out of a lack of coordination in the location and provision of services. The Geriatrics Division had been established to develop a coordinating role in advising the voluntary groups that both State and Federal governments encouraged to provide services.17 However, the potential for developing this role was limited first, by the appointment of nurses as divisional officers - nurses having no authority in medically dominated health services. Second, although one of its principal functions was to encourage collaboration between the voluntary groups that provided services, the Division in fact had no power to compel any of them to take any particular course of action, relying solely on advice and negotiation to achieve its objectives. In this situation services were provided according to how the church and community groups viewed ‘need’ from their own particular perspectives, with the result that while there was a significant increase in services available for the infirm aged, they were fragmented and uncoordinated.18 Following her interview with Divisional officers in the early 1970s, Brigid McCoppin concluded that they had developed a role in which they responded to the demands of a varied clientele. There was little room for implementing policy as they balanced the often-conflicting requirements of a disparate collection of organisations in a series of ad hoc responses. The provision of a subsidy to pay for patients to be cared for in private hospitals while they awaited admission to a Geriatric Hospital, illustrates the confusion amidst which Geriatric Division Officers functioned. It was a step totally at odds with the objective underpinning geriatric services.19
The HCC faced other problems apart from its lack of power in relation to the institutions and community groups that came within its jurisdiction. Since its inception in 1948, the Commission’s activities had been constrained by the apparently poor financial position of the Victorian
17 Annual Report Hospitals and Charities Commission, 1955. The Old People’s Welfare Council, established in the early 1950s, and by the end of the 1960 known as the Victorian Council on the Ageing, also aimed to develop a coordinating role but there are no indications that it succeeded. 18 See Appendix 3 for a summary of these provisions. 19 McCoppin notes the annual cost of this measure was $250,000, McCoppin, 1974, op. cit. p.48.
244 government. The complaint that Victoria was disadvantaged in the allocation of funds by the Federal government was a persistent theme with all Victorian governments since 1942 (when the states had handed over the principal taxing powers to the Federal government).20 Financial strictures were compounded by the apparently lowly status of the Commission within the State bureaucracy. The Health portfolio, as was noted above, was more a reward for party service than a particular focus of policy.21
By the late 1960s, in addition to the expensive muddle in relation to services for infirm old people, the Commission faced a growing demand on the State’s hospital services from a population expanding from immigration and a rising birth rate.22 Its capacity to respond to these was, by then, limited by the openly adversarial relations between the State government and its Federal counterpart as the former reacted to what it viewed as the increasing encroachment into State affairs by the latter. The funding measures introduced by the Gorton Government in 1969 through the States Grants (Home Care) legislation, provided funding for the domiciliary services that could support the type of geriatric service that had been planned in the 1950s.23 However, despite the cost to the State, the Bolte Government in Victoria at first refused this funding, a decision, McCoppin notes, that was quietly reversed a year or so later.24 Hostility between the two levels of government increased when the Whitlam Labor Government came to power in the Federal arena at the end of 1972. It was further aggravated by the strategy this government adopted to avoid having its program of social reform blocked by unsympathetic state
20 J. Holmes, The Government of Victoria, University of Queensland Press, St Lucia, Queensland, 1976,p.180ff. 21 McCoppin, 1974, op. cit.p.95, also see chapter three. 22 Holmes, op. cit. p.163. Between the censuses of 1947 and 1971 the overall population increase had been 70 per cent, Holmes notes that the rate of increase was expected to slow during the seventies. 23 Kewley, op. cit. p.484ff, see chapter five. 24 McCoppin, 1974, op. cit. p.96-97.
245 governments. It made grants directly to local councils and community groups on the basis of submissions from them to the funding body, these were then assessed according to a needs formula determined by that authority.25
The first steps in the revival of the geriatrician’s role, a revival that was given added impetus by Community Health Program funding introduced by the Whitlam administration, were taken in the months before the Labor Party came to power.26 Once again the H.C.C. was the principal instigator of this process as it encouraged the doctors employed in the Geriatric Hospitals to develop plans for establishing geriatric services and a training program to equip medical practitioners to provide such services. Once again, the Commission had the same twofold objective – to provide appropriate hospital and medical services for infirm old people and to make the most efficient use of the State’s hospital beds. The inconsequential position of the Geriatrics Division and its nurse-officers, may be inferred from the fact that the revival of the geriatrician’s role was set in motion by David Race, recently appointed Chief Medical Officer in the Commission, when he chaired the first of what were intended to be regular meetings between the Commission and the medical superintendents and managers of the Geriatric Hospitals.27 The agenda for the first meeting included the planning and decentralisation of geriatric services; domiciliary care programs: the relations between this type of service and the voluntary agencies, local government and local general practitioners; and the relations between State and Commonwealth
25 It was not so much the extent of Federal funding of health services that changed when the Whitlam Government came to power as the way it was provided. Instead of, as in the past, subsidies being made for private expenditure, they were now provided in the form of public expenditure and were thus more visible, Scotton & Ferber, 1978, op. cit. p.97ff. 26 No doubt following the informal decision to make use of the funding for community- based services funded by the States Grants (Home Care) legislation in 1969. 27 VPRS 4523/P2/1010/1973-170. This first meeting took place 25/7/72. Notes in this file suggest similar meetings had occurred at some time in the past but there is no record of them here. Possibly this accounts for the scepticism with which the participants greeted David Race’s remark that he hoped the meetings would provide a source of advice for the Commission in developing policy. The medical superintendents who attended included, H. Tucker (Kingston Centre), John Shepherd (Mount Royal), J. G. Wijeyesekera (Greenvale Village), Bruce Ford, Caulfield Rehabilitation Hospital (which included a Geriatric Division). David Race was appointed to the Commission in 1973, as Chief Medical Officer, following the retirement of John Lindell, due to illness, in 1972. Lindell died the following year. Race was previously a biophysicist in the Clinical Research Unit at the Alfred Hospital, which he followed by several years as Director of the Computer Study Group in the Hospitals and Charities Commission. In 1970 he qualified as a Fellow in the Royal Australian College of Medical Administration, Australian Medical Directory.
246 agencies. The principal concern at this stage, however, was the development of a training scheme for geriatricians to make the work more attractive to doctors at a time when medical work was increasingly being defined in terms of specific skills and knowledge and accredited training programs.28
It was David Race who took the lead in suggesting the Association of Geriatric Medical Officers (AGMOs) assumed responsibility for developing and supervising a training program, with the administrative assistance of the Melbourne Postgraduate Committee.29 Possibly Race’s suggestion followed informal discussions with the medical practitioners involved. Nevertheless, in comparison with the introduction of training programs by other medical specialties, it is notable that the record of this decision is found in the minutes of a meeting sponsored by the Commission, not a meeting of a professional association.30 In the case of geriatric medicine in Victoria, the introduction of the training program was the occasion of the revival of an Association that appears to have lapsed after a few years of activity following its formation in the early 1960s. 31 The introduction of a training program under these circumstances illustrates the dependent nature of the relationship between this group of medical practitioners and the Commission - a relationship that most medical practitioners sought to avoid.32 This is not to suggest that individual practitioners had not given thought to developing their role as geriatricians. In 1967 John Shepherd, medical superintendent of Mount
28 VPRS 4523/P2/1010/1973-170. The trend towards specialisation in medical work in Australia, while slow to begin, accelerated in the 1960s when special interest medical societies, ‘mutual interest groups’, shifted towards the status of ‘qualifying associations’ with ‘formal control over the training and qualifications required of entrants to the sub- profession’. In the course of this process distinctions between the general practitioner and the specialist consultant became more marked and were reinforced by the introduction of differential fees for specialist medical attendance in the system of voluntary medical insurance at the time. Separate registers of specialists were established in each state. Scotton, 1974, op. cit. p.77ff. 29 VPRS 4523/P2/1010/1973-170. 30 For example, the medical practitioners who promoted medical rehabilitation as a specialist field of work worked from an association that had been formed in the mid-1940s as an entity quite separate from the state bureaucracies responsible for the hospitals where these doctors were employed, see Footnote 21, chapter five. 31 Personal Papers Dr John Shepherd. 32 It was not just the closeness of the relationship with a state instrumentality that made geriatricians in Victoria conspicuous. It was their dependence in the relationship and its visibility. Other hospital based doctors were also highly dependent on State and Federal funding to develop their work but this close relationship was masked by, for example, the autonomy of hospital committees of management and by the provision of federal subsidies directly to the providers – the hospitals.
247 Royal hospital had presented plans for a Geriatric Service to the Commission. He did this however, as representative of his institution, not his professional association. Such dependence on the Commission rather than their own professional organisation was typical of the approach Victorian practitioners had taken to their work as geriatricians and while their attitude was understandable in view of their isolation from the mainstream of medical practice, it also reinforced that isolation.
Patient demand for geriatric services has not been mentioned as a stimulus to the revival of the geriatrician’s role. On one hand lack of demand reflects a situation where elderly people simply had no say whatsoever in any arrangements that were made for them. On the other hand it also reflects a situation in which the elderly responded to the possibility of being in a position of needing assistance and not being able to get it, by ‘putting their name down’ for institutional care. From their point of view, responsible provision for one’s old age included taking the necessary steps to ensure such a catastrophe was avoided. Up to the late 1940s and early 1950s, when the Federal government first provided subsidies for age- specific accommodation, it was mostly the poor who took the step of putting their name on the waiting list of one of the benevolent homes. They did so even if it meant accepting a place when it was offered while they were fit, to ensure that if they needed assistance, it would be available. The attitude underlying this practice is illustrated in a short film made by the Kingston Centre (formerly the Cheltenham Old People’s Home) to advertise its facilities.33 The film begins with a view of an elderly, but fit, man, walking through the gates and down the drive, dressed in his best and carrying a small suitcase. The accompanying commentary gives his name and a brief history. After a life-time of hard work, being alone in the world, he is, says the narrator, although still well and able to work, approaching the time when he may not be. It is in preparation for this that he has taken the wise step of applying for admission and now it is his turn to be offered a place where he can see out his days in the security of the institution.
33 Archives Kingston Centre, Cheltenham.
248 When the Federal government began to subsidise, first, age-specific housing in 1954, and then, in 1963, long-term care, the voluntary agencies found a source of funding that enabled them to establish extensive complexes consisting of different levels of accommodation ranging from self-contained flats to long-term care beds. The middle classes were thus able to make responsible provision for their old age by going to live in one of these protected environments, secure in the knowledge that whatever their needs were in the uncertain future, they would be met. The report by the Committee of Inquiry into Aged Persons Housing noted that the provision of funding for institutional care through the Aged Persons Homes Act, 1954, fostered a demand for institutional care.34 In turn this demand would also have fed upon reports of the difficulties faced by many infirm old people in getting ‘a bed’ when they did need permanent care, in the uncoordinated system that existed in the early 1970s. In these circumstances the demand for ‘community services’ came entirely from the doctors who promoted geriatric services and the social workers who promoted the replacement of institutional care by ‘community care’.
From Institution to Community – Re-Situating the Geriatrician The introduction of a training program for geriatricians in the mid-1970s was a major step towards shifting the focus of ‘geriatrics’ from institutional supervision to service provision, but funding provided by the Federal government from the late 1960s, had already begun to change the environment in which geriatricians worked. The first changes came with the funding for domiciliary services provided by the Gorton Liberal- Country Party coalition, but when the Whitlam Labor government was elected in late 1972, they were accelerated and extended. Not only did the physical conditions in which geriatricians work shift outwards from their institutions to the surrounding communities, but for the first time, the cognitive orientation of the geriatric service found a place within the broader medical profession. Victorian geriatricians found fresh opportunities in the early 1970s, to develop their role although their close
34 Report to the Social Welfare Commission by the Committee of Inquiry into Aged Persons Housing, (Chairman) Mr. K. Seaman, AGPS, p.41.
249 alliance with the HCC continued to impede their integration with other medical services and the new medical environment in which they found themselves did not necessarily work in their interest.
Even as the AGMOs was reactivated in October 1972 for the purpose of developing a training program for geriatricians, the conditions in which some of these doctors practised had begun to change. Bruce Ford, Director of Rehabilitation Services at Caulfield, and a member of the training program sub-committee, had appointed D. H. Blake, a physician trained under W. F. Anderson (later Sir William) at Glasgow, to take charge of the Geriatric Division in his hospital. Blake had come to Caulfield from the position of medical superintendent at the Bendigo Home and Hospital for the Aged.35 Blake took over the unit established by Cecil Ashley in the infirmary wards of Caulfield in the 1950s and continued his work with the improved resources that Ford had at his disposal to develop Caulfield as a Rehabilitation Hospital. Blake did so, however, within a hospital organisation focused on the provision of rehabilitation treatment, which he regarded as only one aspect of the practice of geriatric medicine. The other aspect being the provision of ‘adequate … hospital services for geriatric patients’, adequate meaning the facilities of a general hospital.36
Malcolm Scott, formerly geriatrician at Greenvale, had taken on the task of establishing a Geriatric Service at Mt Eliza in 1971, in buildings previously used as an annexe to the Royal Children’s Hospital.37 At the time the Mornington Peninsula, the area served by Mt Eliza, was being transformed from farming and seaside communities to suburban housing
35 See Chapter Five. 36 D.H. Blake, ‘The Planning of Geriatric Medical Services’, Newsletter of the Australian Association of Gerontology, vol 1, no 7, 1968, pp.54-56. While Blake would have been able to develop a service similar to that described in this article in that he may have been able to admit patients from the community to an assessment ward, and he certainly had the facilities of the Alfred Hospital within a short drive by car or ambulance. However, located in a Rehabilitation Hospital, he could not provide care during acute illness as did his physician colleagues at the Alfred. 37 VPRS 6345/512/1867. Mount Eliza had been used as an orthopaedic section by the Children’s, with a special school for children with disabilities, which continued to operate on the site until 1973.
250 estates with industrial production providing work for a growing population.38 Scott’s experience at Greenvale gave him an advantage over his committee of management and he used this to good effect to develop the facilities at Mount Eliza as a rehabilitation centre through which patients passed rather than as a community monument to ‘the aged’.39 He was assisted in this by having only a hundred or so beds at his disposal so there was little scope for providing long-term care at the Centre and building up the waiting list.
Scott turned the situation to good advantage by making the best use of the nursing home beds and domiciliary services that became available in the late 1960s and early 1970s, in combination with the rehabilitative treatment provided at the Centre. Local church halls and community centres were included as makeshift Day Hospitals.40 The innovative use of existing facilities was enhanced by the imaginative deployment of the occupational and physiotherapists allocated to the service. In these circumstances an energetic and pragmatic practitioner, disinclined to be constrained by administrative rules, was able to turn the shortcomings of his institutional setting to advantage. In 1974, three years after taking on this task, he was able to report that the Mount Eliza Centre operated with a turnover of patients exceeding that of any other Geriatric Centre.41
It was Scott’s personal enterprise that contributed to the successful operation of a service that, in its emphasis on restorative treatment, was exactly what the Hospitals and Charities Commission aimed for. This success, however, was achieved at the cost of friction with the committee
38 At the end of 1971 the population of Victoria amounted to three and a half million, much of this increase coming from migrants. The growth in population was accompanied by an extension of suburban development to the outskirts of the metropolitan area. It was in response to this change in the population that the move was made to introduce a Geriatric Service on the Peninsula. Holmes, op. cit. p.163ff, p.175ff, also Victoria Year Book, 1972, p272-273. 39 VPRS 4523/P2/359/7834Pt2, Scott submitted his plans for developing a Domiciliary Care Program in October 1971. 40 A letter from John Lindell in November 1971, in reply to Sir Laurence Hartnett (Committee of Management for Mount Eliza) who had made proposals regarding the Centre following a visit to Geriatric Centres in England, suggests the Commission continued to be short of funds. Lindell wrote that the Commission had, when Day Hospitals were first advocated, spent too much on construction and costs escalated ‘alarmingly’. He went on to suggest the use of Church and Public Halls ‘which can be converted for modest sums and are usually conveniently situated’. VPRS 4523/P2/359/7834Pt2. 41 Minutes Meetings of Hospitals and Charities Commission Officers and Medical Superintendents and managers of the Geriatric Hospitals, 11/9/74.
251 of management, which, in turn, may have disposed the committee unfavourably to accepting the specialist role of the geriatrician.42 Nor it appears, were local general practitioners appreciative of the expertise provided by the geriatrician. In June 1972 Scott described the services provided in the Geriatric Centres, in the Monthly Paper issued by the Victorian Branch of the Australian Medical Association. The emphasis in this short note, on the importance of the role of the general practitioner in providing medical services to ‘the elderly and chronically ill’, suggests that on the whole general practitioners did not welcome the geriatrician’ expertise.43
It is not altogether clear how Community Health Program (CHP) funding came to be used to develop geriatric services in Victoria although there can be no doubt that it was used for this purpose.44 Perhaps in light of the vehement opposition of the State government to most of the reforms introduced by the Whitlam Labor government in the Federal arena there was an element of subterfuge in the manner of doing so.45 It would not be
42 Shortly after Malcolm Scott retired from a full time position at Mt Eliza in 1980, the first locally trained physician geriatricians completed their training and it might have been expected that one of them would take Scott’s position. However a local general practitioner was appointed, Dr David Phillips, FRACGP. 43 AMA (Victorian Branch) Monthly Paper, no 110, 1972, p.4. 44 The introduction to the report on the pilot geriatric service established at Mount Royal in 1973 records that it was Community Health Program funding that made the service possible. Hospital and Charities Commission files record the purchase of a private hospital, Manvantara Hospital, with CHP funding, for the purpose of establishing a geriatric service in the eastern suburbs of Melbourne. VPRS 6345/540/2164; see also Sax, 1993, op. cit. p.97, Sax notes especially that in Victoria, Community Health Program funding was used for geriatric services. The Australian Assistance Plan, also introduced in 1973 by the Whitlam government, promised funding for the regionally-based coordinated community services that would complement geriatric services, Scotton & Ferber, op. cit. p.218. 45 Scotton and Ferber note that the Victorian government was the most antagonistic of all the states to the innovations introduced by this government. They refer to special legislation to prevent public or private organisations in the state from receiving federal grants, the Hospitals and Charities (Institutions and Benevolent Societies) Act 1973, p.103. On the other hand, in an article assessing the achievements of the Community Health Program, which the federal government ceased to fund in 1981, Elizabeth Furler and Michael Howard noted that the Victorian Hospitals and Charities Act was a ‘Trojan Horse’ which allowed local groups to register or incorporate in order to receive funding from the federal government despite the opposition of the state government to such measures. E. Furler & M. Howard, ‘Commentary Sequels to the Community Health program’, Community Health Studies, vol vi, no 3, 1982, p.294. The Victorian government refused to permit the public and private hospitals in the State to take part in the first attempt by the Hospitals and Health Services Commission to amass an organised body of information about the country’s hospitals. However while the State might not have been represented in the statistical material the Commission gathered, information relating to the State’s hospitals did come from written submissions. Appendix V lists authors of written submissions, includes the Department of Health and the Hospitals and Charities Commission as well as public hospitals, Hospitals and Health Services Commission, Report on Hospitals in Australia, AGPS, Canberra, 1974, Appendix V.
252 the first time that a state government used federal government funding without acknowledging its origins. From the point of view of the HCC and that of the institution-bound geriatricians in Victoria, the Community Health Program offered possibilities, on the one hand, for implementing the form of service the Commission believed was the most appropriate response to managing long-term illness and disability, and on the other, for integrating the work of geriatricians into a new model of medical practice.
The CHP was intended to fund health services aimed at addressing problems neglected within existing medical services, particularly the needs of patients whose ailments could not be cured, but whose disabilities could be limited or even prevented by the services of a team of health professionals under medical direction. While the geriatric service as the HCC envisaged it, was hospital based, it was aimed at establishing and supporting ‘social competence’ rather than cure, in order to diminish the need for institutional care, and in this respect, was an ideal expression of the values inherent in the CHP.46 From the perspective of the institution- bound geriatricians, the CHP promised to integrate the medical work of ‘geriatrics’ within a broader model of medical knowledge and service. In addition to promoting the provision of medical services for the chronically ill and disabled, CHP funding was available to establish a knowledge base derived from epidemiological and sociological studies of health and illness in their ‘natural’ environment to complement that produced in hospitals and biochemical research.47
In another respect however the geriatric services planned by the Commission highlighted an ambiguity in the Community Health Program which is worth mentioning, because it illustrates the complexity of the environment in which the geriatric service, and the role of the geriatrician, finally emerged. The list of objectives of this Program contained reference to the need for health professionals and individuals in the community to
46 See Chapter Five, and Scotton & Ferber, op. cit. p.102-103, p.105-106. 47 Report from the National Hospital and Health Services Commission, ‘A Community Health Program for Australia’, Interim Committee, 1973, p.1.
253 come into a ‘dynamic’ relationship in ‘seeking to solve the local community’s health and related problems’. This objective implies some agreement between medical practitioners and ‘the community’ about the nature of those problems. In relation to the geriatric services there was no such coincidence of opinion about the needs of infirm old people. The experts - the Commission and the geriatricians - thought in terms of the provision of services. The community thought in terms of the provision of beds. In view of there being no change in the longstanding practice on the part of the Victorian government of encouraging voluntary groups to take on the task of providing services, this difference of opinion promised to pose some difficulty in the process of developing geriatric services. It was the failure of the medical view of managing old age infirmity to dominate over the community view that contributed to the retarded development of the first attempt to establish geriatric services.
Two committees were in existence in the early 1970s, drawn from members of the community, with the objective of developing provisions for infirm old people in the northern and eastern suburban areas. Both local committees focused on establishing large institutions with several hundred beds. In both cases the Geriatrics Division intervened in the only way available to it, indirectly and cajolingly, to divert the committees’ attention towards what expert opinion believed was the preferable solution. This approach was successful but time-consuming and probably expensive. Certainly this was the case in relation to the Peter James Centre in the eastern suburbs, because Dr Lionel Cosins, one of the English pioneers in geriatric services, was brought out to conduct a survey of the resources in the area around the proposed centre, with the aim of redirecting the committee’s attention to the ‘correct’ decisions.48
48 Personal communication from Mrs Marion Shaw, March, 1997, Mrs Shaw, as noted in chapters two and three, was appointed officer in the Geriatrics Division in the Hospitals and Charities Commission after John Lindell died in the early 1970s. Concerned at the plans she was aware the two local committees had for establishing institutions with large numbers of beds, she took the only steps open to Divisional officers, to gently redirect attention towards the provision of services. She encouraged the committee planning the north-eastern suburbs project to invite doctors from Mount Royal to join them, Dr John Shepherd and Dr Boyne Russell. In regard to the eastern suburbs project, she advised bringing Lionel Cosin to Victoria to report on the requirements necessary to develop a geriatric service, see L. Cosin, ‘Report on Report on Eastern Suburbs of Melbourne Geriatric Services Development & Manvantara Hospital, 1979, Hospitals and Charities Commission, Melbourne.
254 Despite their reliance on the HCC for the impetus to develop their role, Victorian geriatricians did make their own contribution to this effort. Malcolm Scott’s work in establishing a geriatric service at Mt Eliza is but one example. Although Scott’s work was important in demonstrating the role of the geriatrician through the implementation of services, it was John Shepherd who provided a formal definition of the work in a lecture in 1971 where he outlined his plans for a ‘Total Geriatric Service’. In addition to describing the structure of this service he also defined the patient for whom the service was intended. The geriatrician, he said, dealt with those patients, who were, by and large, over the age of 75, although age was not the principal factor identifying the geriatrician’s patient. Such patients presented a clinical picture not easily interpreted according to the approach cultivated in the acute hospitals and general practice, because of the multiplicity of pathological conditions and because the physical and mental components of a patient’s condition were not readily distinguished.49 The term Shepherd used to describe the geriatrician’s approach to this patient was ‘assessment’, a process that encompassed the whole spectrum of factors that contributed to the complex clinical picture presented by these patients – physiological, social, psychological and sensory.50 Shepherd’s definition implies a role for the geriatrician in the diagnosis and treatment of acute conditions. However, it was clear from when the Hospitals and Charities Commission first introduced the role of geriatrician in the fifties, that treatment during acute phase of illness was not likely to be included.
In 1974, a year after the pilot program in the service proposed by John Shepherd, had been established, David Race addressed the representatives of the local communities that would be served by the geriatric service planned for the Ovens and Murray Home for the Aged at Beechworth.51 His explanation of the service made it clear the Commission’s view of the
49 SJH Shepherd, ‘A Total Geriatric Service’, Appendix 1 in B. Russell & R. Dargaville, A Geriatric Community Care Service in Brunswick, Mount Royal, June, 1976. 50 Ibid. 51 The Beechworth institution was one of the last benevolent homes to be transformed into a Special Hospital for the Aged, John Lindell opened a new nursing home ward there in 1965, that was named in his honour. In the early 1970s Dr D. McDonald, an emigrant from Scotland, (one of a number of English doctors appointed to develop geriatric services in Victoria) was appointed ‘geriatrician’, I. Hyndman, Out of the Goldfields, A History of the Ovens and Murray Hospital for the Aged, Beechworth Hospital, Beechworth, Victoria, 1993, p.178ff. McDonald was one of the first candidates when the Diploma of Geriatric Medicine was introduced in 1975.
255 geriatrician’s role had not changed since John Lindell first introduced it in the late 1950s.52 Certainly the Commission wanted to shift the focus of the geriatrician’s work away from the supervision of institutional care. However, rather than emphasising the complexity of the clinical presentation of sickness in the elderly, Race focused on the need to develop the social provisions to support infirm old people to remain at home. The acute hospitals already provided adequate medical services, he said: what was necessary were the community services to complement these for elderly people whose conditions could not be altered by medical science. The geriatrician would coordinate medical and welfare services from a base in the geriatric hospitals, a base that was linked into the acute services in the public hospitals and to domiciliary services in the community. There was no difference between this outline of the role of the geriatrician in the early 1970s and that given by John Lindell in 1955.53
In justifying the need for the geriatric service David Race made explicit reference to one of the principles of social medicine, a rare occurrence in discussions of health services in Victoria.54 Perhaps the rise to prominence of the advocates of social medicine in the Federal bureaucracy had conferred a degree of respectability on this view of health and sickness. Race related improvements in health and longevity to social provisions rather than medical science. Most of these changes, he said, ‘have been due to improvements in housing, hygiene and other sanitary measures, with improvement in food, (and) industrial safety’. It was thus social measures that would deal most satisfactorily with the new needs associated with such changes. His promotion of social medicine was somewhat diminished by his subsequent remarks to the effect that the development of geriatric services was less costly than providing special hospitals for this type of patient. There was a need for a continuing medical role in the management of old age infirmity but, ‘like all these services, they are very expensive and … we are starting to price ourselves out of the market’.55 The Commission’s promotion of the role of
52 The Victorian Hospitals Sector No 2, in conjunction with the Hospitals and Charities Commission, Integrated Geriatric Care – The Need for Co-ordination, Proceedings of a One Day Seminar, November, 1974, p.7-8. 53 Hospitals and Charities Commission Annual Report, 1956. 54 For social medicine see Chapters Two and Five. 55 Integrated Geriatric Care, op. cit. p.7.
256 geriatrician, and social medicine, was inextricably linked to the need to make the most efficient use of the state’s health and welfare resources.56
From the early 1970s the geriatric hospitals began, very slowly, to reorganise their facilities to provide services in the form described by David Race. At Mount Royal, for example, the success of the pilot geriatric service set up in 1973 led to the reorganisation of the hospital’s facilities into a divisional structure with each division providing a geriatric service to a specific locality.57 The older establishments continued to provide long-term care (although to a diminishing extent through the 1980s) and to maintain their hostels and other forms of accommodation, but the working environment gradually began to resemble the model promoted throughout the sixties at almost every annual Geriatric Conference.58 The role of the geriatrician began to change but it was a slow, gradual and uneven shift, barely perceptible amidst the enduring elements of fragmented service provision, committees of management reluctant to relinquish their authority, and a very slow process of recognition from other fields of medical work. The introduction of the role of the geriatrician as service provider and the characteristic hospital setting for this work, took place, as it did in the 1950s, in circumstances of urgency and expediency, dominated by the Commission’s need to respond to the problem of managing hospital resources overtaxed by an expanding population, uncoordinated in planning and development, amidst disputes over funding allocations between State and Federal governments.
The Brunswick Community Care Program described by John Shepherd in his 1971 lecture was introduced at Mount Royal in 1973, under the direction of a physician - Boyne Russell. Russell had joined the medical staff at the hospital in the previous year after her return from England where she worked with Tom Wilson, one of the first consultant
56 David Race may have been influenced by the ideas disseminated by Thomas McKeown in his 1968 visit to Australia, or at least his text, The Balanced Hospital Community, published a few years previously. McKeown expressed sentiments similar to Race’s more elegantly in a later text, when he defined quality of care to mean ‘(a) the standard of care (how well we do what we do), (b) effectiveness of care (whether what we do is worth doing), and (c) efficiency of care (whether what we do makes better use of resources than the available alternatives’, he made it clear he was not concerned with ‘… the cost/benefit issues which arise in relation to efficiency’, T. McKeown, The Role of Medicine, Dream, Mirage, or Nemesis? 4th reprint, Basil Blackwell, Oxford, 1989, p.138. 57 Annual Report, 1977. 58 Geriatrics Conference, 1956-1966, Geriatrics Conference, 1967-1976, op. cit.
257 geriatricians, in the service he established at Barncoose Hospital in Cornwall.59 The Mount Royal geriatric service was only one of a number of developments along these lines that began in the early seventies. Reference has already been made to Mount Eliza and similar changes were introduced at the Cheltenham Old People’s Home. The shift in emphasis at the latter was marked by replacing the name ‘Cheltenham Old People’s Home’ by ‘Kingston Centre’. None of the changes, however, was so innovative that it provided a service in which psychiatric and general medical services were integrated. It wasn’t until the early 1980s that an integrated service was established at Mount Royal.
In view of the developments that took place in country and metropolitan areas, the question could arise as to why I have given prominence to events at Mount Royal. It was Mount Royal, with its link to the Royal Melbourne Hospital, at the intellectual centre of medical work in Victoria, and its committee of management which included influential businessmen, that provided additional opportunities for geriatricians in Victoria to develop their role. These circumstances did not exist to the same extent in the other institutions, isolated as they were from the centre of the State’s political, medical and business communities in the city area, with committees of management made up from local suburban or country town communities.60 The difference in standing between Mount Royal and the other Centres was marked at the end of the 1970s when the institution was given permission to change its title to ‘Mount Royal Hospital’ in view of the services it provided to the chronically ill and disabled in general.61
59 Personal communication from B. Russell 12/12/97. Wilson’s career is described in ‘Comment’, Age and Ageing, vol 3, 1974, pp.69-72. He was, it appears, the first physician geriatrician to make a special study of incontinence. Russell carried on this tradition, establishing the first continence service at Mount Royal. An early study of this topic at the Queen Elizabeth Centre at Ballarat was reported on at the Geriatrics Conference in 1968, Geriatrics Conference, 1966-1976, op. cit. 60 The qualities brought to their task by the members of committees of management of hospitals in Victoria were vital elements in the successful operation of a hospital where, although the State government provided a substantial proportion of funding, responsibility for administration lay with the committees of management. The importance of the committee of management – its competence and social and political clout - in the development of any type of hospital in Victoria is shown in McCoppin, 1974, op. cit. and two more recent theses on the topic of Victoria’s hospital system, C. Walker, ‘The Emergence of the Hospital System in Melbourne: 1846-1975’, PhD Thesis, La Trobe University, 1994, and Collins, 1999, op. cit.; for a briefer account see, McCoppin, 1983, op. cit. pp.376-377. 61 VPRS 4523/P2/8283.
258 Essentially, the service developed to address the needs of elderly people in Brunswick, consisted of one ward in Mount Royal Hospital, reclassified from nursing home to acute care so that patients could be admitted directly, some short term beds for rehabilitation treatment, and others to be used to admit old people cared for at home to provide some respite for their carers. When a longer period for rehabilitation was necessary, the hospital’s rehabilitation unit was used and, when necessary long-term care beds in the other wards of the hospital. These existing and refurbished facilities were linked to a Day Hospital and a Day Centre in the community and the whole service was limited to the population of the municipality of Brunswick. The aim was to provide a service that could respond to urgent need on the day of referral, and to the less urgent within 48 hours.62 This mode of operating was in complete contrast to previous arrangements for admission to Mount Royal, in which medical opinion regarding need for admission ran second to management of the waiting list. The establishment of geriatric services at the geriatric hospitals in the early seventies provided the long-awaited opportunity for medical staff to gain authority regarding admissions.
The Brunswick Community Care Program had its own staff – physician in charge, social worker, nurses, therapists, clerk and carpenter (the provision of assistance in removing impediments to independence in patients’ homes was part of the service). Junior medical staff came from the Austin Hospital, either because the Royal Melbourne was unable to supply them, or because Russell was able to arrange this more easily with the Austin. As in the past, the incorporation of time at Mount Royal into the duty roster of trainee doctors was not accompanied by any theoretical component. If Boyne Russell’s teaching struck a spark of interest in any of these students, it was quite likely to be squashed by their supervisors in the acute hospital.63 Nor, during the period of the pilot program, did she have a Registrar appointed to the service, which made communication with the acute hospital more complex. Referral to the service was accepted from families, neighbours or professional health workers in the
62 Russell & Dargaville, op. cit. 63 Personal communication from B. Russell, 12/12/97.
259 community, and leaflets describing the service were distributed in the languages spoken by the various migrant groups in Brunswick. Russell’s flexible attitude to referral was essential if the benefits of the service were to be disseminated amongst both lay and medical communities in the area. The combination of factors that often underpinned the collapse of an old man or woman already meant they were neglected within existing medical services, oriented, as they were, towards identifying a single cause of disease and divided along the lines of physical and mental disease. To rely only on a medical interpretation of this group, by either the general practitioner or the hospital medical officer, would be to miss the very group the service was intended to assist.64 Nevertheless, establishing personal contact with these medical practitioners was an important component of Russell’s work. A professional relationship could be the basis for inserting the geriatric service into existing hospital and medical services available to Brunswick residents.
Slowly, and unevenly, over the years from the early to mid-1970s in Victoria, as the geriatric service gradually shifted the focus of geriatric medicine away from institutional supervision, the geriatric patient defined by David Wallace in 1959 began to fade from view.65 This patient, the institutional inmate whose general frailty, compounded by social infirmity – the lack of money, friends or relatives - brought him or her, into the Geriatric Hospitals, was replaced by the patient G.V. Davies, the Victorian psychiatrist, had identified a decade earlier; one described by the British geriatrician, John Agate, as most likely to be female, and in the eighth decade of life. It was around this point that long-term degenerative conditions began to take a toll that was reflected in mental changes and difficulties in going about the business of everyday life.66 In Victoria however there were two views of this patient, views that were not completely dissimilar, but whose differences had implications for the development of geriatric medicine.
At a Symposium on the Medical and Social Problems of Ageing, in Melbourne in 1976, Russell described the geriatric patient in terms similar
64 Russell & Dargaville, op. cit. p.11-12. 65 Wallace, 1959, op. cit. p.40. 66 Davies, 1961, op. cit. pp.152-154; J. Agate, The Practice of Geriatrics, William Heinemann Medical Books, Ltd, London, 1963, p.6-7.
260 to those used by John Shepherd in his initial outline of the service. Mostly over 70 years, mostly female, and, in general, the typical patient’s multiple problems of ill health were aggravated by an inability to adapt to changes in her social circumstances, changes that included a diminishing capacity to participate in the social life of her neighbourhood, family or friends. The isolation that resulted compounded her physical and mental problems.67 The majority of people treated by the BCCP spoke English as their native language and the number of non-English speakers was small in relation to their proportion in the Brunswick population. These figures suggested that in future, the widowed, 70 plus, women – the characteristic patient of the geriatrician – would also experience difficulties arising from cultural differences.
It was in moving the service out into the community, building on the contacts she made with local GPs, private hospitals, nursing homes and rest homes, that Russell came into contact with the patient that British geriatricians had established as typical. Poverty continued to be a characteristic of many of the patients treated in the service simply because of its location in a working-class area. The old men who had always been prominent in the wards of Mount Royal were still there, as were the old women refused admission by the public hospitals when they suffered a stroke or fractured femur because of the problems anticipated in discharging them. A promise that they could be admitted to the acute ward of the Geriatric Service following treatment in the public hospital soon changed an admitting officer’s point of view.68 At the same time, however, in going out into the community, Russell came into contact with potential patients who would never cross the threshold of a public hospital. In establishing contacts with general practitioners and the proprietors of the private hospitals, nursing homes and rest homes in the Brunswick area,
67 B. Russell, ‘Geriatric Service Monitoring’, in Multidisciplinary Gerontology: A Structure for Research in Gerontology in a Developed Country, ed I.R. Mackay, S. Karger, Basel, 1977, p.111. 68 Russell & Dargaville, op. cit.
261 Russell opened up the field of practice of the geriatrician in a manner that had not been achieved previously at Mount Royal. 69
The patient Boyne Russell identified, as was noted above, was not unknown to the advocates of geriatric medicine in Victoria. The significance of Russell’s definition was that it was made by a physician geriatrician within an organisational setting specifically established to cater for the needs of this group of patients. The distinctive character of the geriatrician’s patient may be discerned by comparison between Russell’s definition in her report, and that of Bruce Ford, medical rehabilitationist at Caulfield Hospital, in a text he published in the early 1970s.70 Ford described the group of patients for whom the geriatric service was provided, as, ‘the group of dependent adults who must be provided with services and facilities to compensate for what they can no longer do for themselves because of physical dependency, intellectual deterioration or sickness’.71 He also noted that women predominated in this group and that the factors that precipitated individuals into this group combined elements that were medical and social.
Ford’s definition differed however, in that he characterised the condition of this group as dependency - a condition related to the individual’s social situation so that she was obliged to call upon publicly funded services. The disorders which undermine the capacity to ‘get about and think clearly’ were only given a formal interpretation of dependency when the person in question has insufficient resources to compensate for diminishing physical and mental competence. As Ford elaborated the physical and mental disorders that were the basis of dependency, he covered a range of disorders similar to those described by Russell. The
69 It was noted in Chapter Three that the introduction of rehabilitative treatment into the benevolent institutions and the subsequent recognition of this type of hospital care for the purposes of claims upon hospital insurance, opened up the possibility of a more affluent clientele for the Geriatric Hospitals. Possibilities, however, were limited by the lack of access geriatricians had to treatable patients and those treated in the private hospitals or the private sections of the public hospitals. When the restorative methods promoted in the geriatric hospitals were taken up by the voluntary agencies in their institutions, ‘geriatrics’ was also extended into the middle classes. In 1979 Boyne Russell addressed the Private Geriatric Hospitals Association of Victoria on the topic of integrating public and private sections. The president of this new group was Dr Michael Nissen described as ‘geriatrician’ to Montefiore Homes, VPRS 4523/P2/1002/1973-53. Malcolm Scott would also have achieved a similar broadening of the patient base for geriatricians in his work at Mount Eliza. 70 B. Ford, The Elderly Australian, Penguin Books, Ringwood, Australia, 1979. 71 Ibid. p.6.
262 difference was that he focused on the condition of dependency and its management, while Russell emphasised the medical expertise required to manage illness in this group of patients. They require, Russell said, a service which ‘is different in pace, concept and range of facilities’.72 Russell’s view of the matter appears to coincide with John Shepherd’s remarks relating to the complexity of the clinical picture presented by these patients. Russell’s view provides a local example of that publicised by the West Australian physician, R. B. Lefroy, in his mid-1960s article when he defined geriatric medicine as ‘the practice of medicine among the elderly, so arranged that their care is based on an understanding of the physical, social and mental factors responsible for their disabilities’.73
Ford, on the other hand, reflected the ideas underlying the specialty of medical rehabilitation. His notion of dependency was derived from understanding this form of medical practice as the medical supervision of a process of retraining of a disabled individual and his or her management within a coordinated range of welfare services, medical work quite separate to the diagnosis and treatment of disease. The special skill of the medical rehabilitationist lay in the capacity to combine an understanding of the requirements of the medical management of chronic conditions with an understanding of the psychosocial and vocational problems experienced by this group of patients, in addition to skills of management and leadership.74 The rehabilitation of an old person certainly provided a different set of problems from those of a younger person, ‘having restored an old lady or gentleman to the optimum level of independence, they (the medical rehabilitation specialist) had a customer for life’.75 The association between the rehabilitationist and this ‘customer’, however, was a matter quite separate from that patient’s treatment for acute illness. In this focus on ‘post-acute’ health care, medical rehabilitation fitted more readily into the Community Medicine Program than did geriatric medicine when it included an acute care component. It was in this respect that D.H. Blake, the physician Bruce Ford appointed in charge of the Geriatrics Division at Caulfield Hospital, felt he was only doing half of what he
72 Russell, 1977, op. cit. p.109. 73 Lefroy, 1966, op. cit. p.206. 74 Ford, 1996, op. cit. pp.117-119, also, ‘Medical Rehabilitation’, Editorial, MJA, vol 1, 1974, p.908. 75 Ford, 1979, op. cit. pp.100-103.
263 believed constituted geriatric medicine. However, as has been made clear throughout this section, the emphasis on rehabilitation and dependency coincided exactly with the aims of the Hospitals and Charities Commission in establishing geriatric services.
Making Geriatricians The development and implementation of a training program highlighted some of the ambiguities surrounding the development of geriatric medicine in Victoria. These were, first, the question of whether the provision of acute care would be included, and second whether geriatric medicine would be a ‘special interest’ field of general practice, or a specialist consultant field of practice associated with accreditation by the Royal Australasian College of Physicians. The Hospitals and Charities Commission was consistent in the view that geriatrics would be associated with age-specific rehabilitation services, but there was sufficient ambiguity in the Commission’s approach to leave open the possibility that acute care could be included. The Commission’s stance in promoting ‘post-acute’ rehabilitation services was, however, reinforced by the form of funding provided by the Federal government. It was expressly intended to cultivate a field of medical practice outside the acute hospitals to provide services for conditions related to chronic illness and disability, that were neglected there. A further source of ambiguity arose from the desire of local medical practitioners to preserve their identity as service providers, an identity that was both bolstered and, at the same time, threatened by moves to establish geriatric medicine as a sub-specialty of general medicine.
Overall, the tendency in Victoria was to establish the role of the geriatrician as a special interest in general practice. From the point of view of the Hospitals and Charities Commission the principal interest in funding a training program was to provide medical staff for the geriatric services it wished to promote. In a medical profession where work was increasingly defined in terms of specific skills and training, a training program promised to encourage doctors to take on work that John
264 Shepherd described as the ‘ugly duckling’ of medicine: … the geriatrician receives patients after everyone else has had their ‘go’. The patients have gross deterioration … and the geriatrician is expected to put them back into circulation by active rehabilitation. Very few like this work … [it’s] difficult to interest doctors in gross deterioration.76
Shepherd, a general practitioner who had made a career as medical superintendent/geriatrician, had himself, in the late 1960s, begun to explore the possibility of linking training in geriatric medicine with the postgraduate training supervised by the Victorian Faculty of the Royal Australian College of General Practitioners. With the psychiatrist, Herbert Bower, and Horace Tucker, medical superintendent of the Kingston Centre, Shepherd had formed a Geriatric Study Group within the Victorian Faculty of the College, with the objective of inserting education in geriatrics into the experience of general practitioners. This group had, to this point, shown no interest in joining the Victorian branch of the Australian Association of Gerontology, formed following the establishment of the national Association in 1965. The minutes of an early meeting of the Study Group indicate that it hoped to assist the College with a geriatrics component in training courses and continuing education.77
When David Race announced, in July 1972, that the Commission was prepared to support the development of a training program for geriatricians, the project to educate GPs shifted to a revived Association of Geriatric Medical Officers.78 There is no evidence of further activity on the part of the Study Group, but John Shepherd continued to cultivate his association with the Victorian Faculty of the Royal Australian College of General Practitioners. In time, when the Diploma of Geriatric Medicine became available, parts of this training program were incorporated into the continuing education courses and postgraduate training organised by the
76 Personal papers, Dr John Shepherd. 77 Ibid. 78 At the meeting in July, David Race noted that the constitution of the Association permitted this course of action and suggested that the Melbourne Postgraduate Federation be asked to assist with the administration of the program. Minutes Meeting Medical Superintendents and Managers of the Geriatric Hospitals, 22/2/74. For postgraduate medical training in Australian see McIntosh, op. cit, also, K. F. Russell, The Melbourne Medical School 1882-1962, Melbourne University Press, Carlton, Victoria, 1967, p.162, p.185.
265 Victorian Faculty.79 There was no conflict in this association between geriatric medicine and general practice. The ideas the Commission had regarding the role of the geriatrician did not preclude a close association between the two areas of practice. In fact the introduction of the Diploma program opened up the possibility for general practitioners to develop a special interest in geriatrics, an interest that fitted with the Commission’s desire to staff its services. This became clear in the course of discussions relating to the training program. Bruce Ford, Director of Rehabilitation at Caulfield Hospital, questioned why any doctor would undertake the Diploma course, which, incidentally, meant paying a fee that in the early stages was set at $300. David Race said in reply that the Commission would recognise graduates of the program as specialists and pay them accordingly.80 The retention of these specialists within the Victorian health service system, and within the ranks of general practitioners, would be assured because this ‘specialist’ qualification would not be recognised by the national Specialist Qualifications Advisory Committee, nor by the Health Insurance Funds.81
The Hospitals and Charities Commission’s conception of the role of the geriatrician coincided with the broader aims of the national movement to define and cultivate a field of non-acute medical practice through the reports and funding programs of the Hospitals and Health Services
79 The Family Medicine Program, funded by the National Hospitals and Health Services Commission as part of the Community Health Program, was intended to assist general practitioners to develop their own specialist skills. The term ‘family medicine’ appears to have been adopted by GPs to indicate the particular form of community setting for these doctors who provided personal medical services. A letter from Dr M. O. Kent-Hughes to John Shepherd dated 3/3/1970 suggests that the term ‘Family Medicine’ was already used by GPs to define the scope of general practice as a specialty in which ‘the whole person and the whole family is treated’, before the term was associated with the program funded by the Whitlam Government, Personal Papers Dr Shepherd. Kent-Hughes had long been an advocate of postgraduate qualifications for general practice. He had been involved in the decision that, from 1965, future candidates for membership of the Royal Australian College of General Practitioners should pass an examination. He was President of the College in 1968 when the College Vocational Training Program was announced, Wilde, 1998, op. cit. pp.4-10. 80 Minutes Meeting Medical Superintendents and Managers of the Geriatric Hospitals, 22/2/74. The Hospitals and Charities Commission also contributed $7000 in the form of an annual grant towards the expenses of running the course. 81 Scotton, 1974, op. cit. p.83, see also chapter five. The specialist geriatricians recognised by the Hospitals and Charities Commission would not be recognised by the National Specialist Recognition Qualifications Advisory Committee.
266 Commission.82 This was particularly the case in relation to the promotion of the role of general practitioner by the Hospitals and Health Services Commission (H&HSC) through the Family Medicine Program and the training programs initiated by the Universities Commission. The introduction of the Diploma in Geriatric Medicine fits into this emphasis on the role of general practitioner. At the same time, however, the Association of Physical Medicine and Rehabilitation, and the Australian Geriatrics Society, both sought to take advantage of the shift in orientation in funding for medical services at the Federal level, to promote their respective fields of work by applying to the Royal Australasian College of Physicians for recognition of their training programs as part of physician training.83 Doctors who qualified under these schemes would receive national accreditation, including recognition as specialists by the national committee and the health insurance funds, so the possibilities for the general practitioner geriatrician were limited even before they were established.
John Shepherd may have had thoughts of aligning geriatric medicine with general practice, but Malcolm Scott, who drafted a proposal for the Diploma program, clearly expected that, in time, it would be absorbed into the training programs then being developed by the Association for Physical Medicine and Rehabilitation and the Australian Geriatrics Society. Bruce Ford commended Scott’s draft as being an improvement on the existing Diploma of Rehabilitation Medicine. Scott himself emphasised the benefits of developing a Diploma program with content that could be absorbed into either of the above training programs – if only to save the College from getting mental indigestion as it considered claims for recognition from both specialist societies.84 Bruce Ford, also a member of the sub-committee responsible for developing the program, did not see any need for an age-related rehabilitation training program. The emphasis on age, he said, reiterating the argument he made in an article
82 The Community Health Program Report was the first of these, it was followed by the Report of the National Committee of Inquiry led by Mr. Justice W. O. Woodhouse, ‘Compensation and Rehabilitation in Australia’, AGPS, Canberra, 1974 and Report of the Working Party on Rehabilitation Medicine and Geriatrics, ‘Rehabilitation Medicine and Geriatrics’, AGPS, Canberra, 1976. 83 ‘Medical Rehabilitation’, MJA, vol 1, 1974, p.907-908; ‘Miscellanea’, MJA, vol 2, 1972, p.1154. 84 Minutes Meeting Medical Superintendents and Managers and Representatives of HCC, 12/12/73.
267 published in 1973, led to ‘boxing’ people in a manner that narrowed the field of effectiveness of any services.85
Ford’s views on education in the medical care of the elderly had been conveyed in a letter to the Hospitals and Charities Commission in October 1973. As a member of one of the committees assisting the H&HSC, he suggested the Commission encourage the incorporation of some aspects of geriatric medicine into the Family Medicine Program then being developed by the Royal Australian College of General Practitioners.86 Scott and Shepherd both affirmed that age could not be separated from disability, the former concluding that, in the short term, the value of the Diploma program was that it would get things started. The discussion was brought back to ground with the remark by the manager of Mount Royal Hospital that the point of the training program was to provide geriatricians – giving other concerns too much play could defeat this object.87
Why did the Australian Geriatrics Society not take on the project of developing the Victorian diploma? The obvious answer to this question is that the Society focused its attention on establishing training in geriatric medicine at the level of physician training.88 This did not suit the aim of the HCC in developing a workforce to staff its geriatric services - as David Race’s reply to Bruce Ford makes clear. Even if Race had been open to the Society being involved, it was by no means certain that it would be successful in gaining the College’s approval of its training program and the introduction of a training program to encourage doctors to take positions as geriatricians would have been further delayed. It was not until the second half of 1975 that the College finally agreed to recognise geriatric medicine, and by then, the first candidates in the Diploma program were halfway through their first year.
85 Ford, 1973, op. cit. 86 VPRS 4523/P2/1010/1973-170, letter dated 22/10/73 to the Secretary of the Hospitals and Charities Commission from Bruce Ford. 87 Minutes Meeting Medical Superintendents and Managers and Commission officers, 13/3/74. 88 Lefroy, 1988, op. cit. p.70. In the early 1970s the Royal Australasian College of Physicians took steps to phase out the Membership examination and to replace it with a system of physician training that was more specific in its content and linked to the accreditation of suitable training positions. The Membership examination was replaced with the Fellowship, Part 1 examination and eligible candidates had to have completed an approved Basic Physician Training program in an approved institutions, W. J. Benson, ‘The History of the College Examination’, in Wiseman, 1988, op. cit. p.4.
268 Other interests were also involved. Although the Australian Geriatrics Society held its inaugural meeting in Melbourne, a Victorian branch was not formed until the 1980s and Victorians were not listed amongst the early office holders. These details suggest that interest in the national society was not strong amongst Victorian geriatricians. The revival of the Association of Geriatric Medical Officers only days after the Australian Geriatrics Society was formed in late 1972, gives the appearance of asserting local interests to support a local project – the development of the Diploma program. No doubt the Hospitals and Charities Commission did insist on the Association taking on the task of developing the training program but at the same time, some Victorian geriatricians may have had their own reasons for supporting a State based project, as opposed to a profession oriented one.
Many of these doctors did not have the higher qualifications that would make them eligible for the College qualification. Once the Society succeeded in establishing geriatric medicine at the highest level of qualification in the medical profession, the general practitioners would be relegated to an inferior position. However if the Diploma program were established and supervised by the State based Association of Geriatric Medical Officers, these practitioners would be able to maintain their own position as specialists. The re-activation of the Association was a means of maintaining the position of general practitioners in providing specialist services. These comments should not be taken to suggest that Victorian geriatricians were against the development of a role for the specialist physician in geriatric medicine: just that they were acting to protect their own bailiwick.
The first candidates for the Diploma of Geriatric Medicine began their training in February 1975.89 All nine met the requirement of a minimum
89 In a letter thanking the Acting Chairman of the HCC for attending the inauguration of the course, John Shepherd listed: L. C. Jago (whose appointment to the position of medical superintendent of the Kingston Centre depended upon completing the course), D. S. McDonald, (Ovens and Murray Home for the Aged at Beechworth), K. W. Shannon from Warracknabeal, J. F. O’Callaghan from Warrnambool (one of these already had an association with the Grace McKellar Centre at Geelong), Dr Hill, Ballarat (possibly already employed at the Queen Elizabeth Centre there), and E. Morrison, P. Gladwell, G. Bearham and D. Rodda, all of whom were employed at Mount Royal Hospital.VPRS 4523/P2/381/7- 105. The association between nearly all these doctors and institutions subsidised by the Commission, confirms the purpose of the Diploma as a means ensuring a qualified staff for the Geriatric Hospitals.
269 of three years postgraduate experience, and they embarked upon a two- year program of 30 weeks attendance per year. In the first year they met for one day each week for lectures, discussion groups, visits to institutions, and case presentations. The second year was devoted to practical work in an accredited institution under the supervision of two experienced doctors selected by the committee established to supervise the course.90 In addition one full training day was held weekly at Mount Royal. Candidates were assessed through examinations and the submission of written work. In view of the aim of the course, that is to equip doctors with the skills and knowledge to undertake the process of assessment and the supervision of ‘total care’, the training program was wide-ranging. It covered the topic of gerontology – by which was meant the biology, physiology and psychology of the ageing process; and ‘social’ gerontology in the form of services for the infirm aged, geriatric medicine, geriatric therapeutics, epidemiology and demography and administration of services.
By the mid seventies, when the course was introduced, there was a wide range of material on ageing to draw upon, much of it from overseas, but some also from local sources.91 The local material reflected developments in biology, in MacFarlane Burnet’s work, and that of Arthur Everitt, whose studies of ageing rats were one of the earliest Australian
90 Minutes of the first meeting of the Victorian Postgraduate Geriatric Medical Training Program, in January 1975, lists members as follows; Drs Shepherd, Russell and Barratt from Mount Royal (Barratt, a doctor without any specific qualification in relation to this work, replaced Robert Butterworth, physician in charge of the Geriatric Unit at Mount Royal, when he died prematurely in July, 1973), R. H. Aldous (Bendigo Home and Hospital for the Aged), H. Tucker and D. H. Blake (Kingston Centre), C. G. Burt (Willsmere Psychiatric Hospital), J. G. Wijeyesekara (Greenvale Village), M. Scott (Mt Eliza), P. J. White (Department of Health), M. Nissen (medical superintendent Montefiore Homes). Bruce Ford represented Caulfield Hospital where the Geriatrics Division provided training posts in geriatrics as an aspect of medical rehabilitation. His comments during discussions regarding the development of the course made it clear he did not see much point in it. By 1981 his repeated absence from meetings led the Committee to inform him that representation from Caulfield was not required, Minutes Meeting Training Committee, 6/7/81. 91 SJH Shepherd, ‘The Evaluation of a Postgraduate Medical Training Programme Leading to a Diploma in Geriatric Medicine’, paper presented at the 1978 meeting of the International Association of Gerontology. The texts noted in this section are taken from a Reading List for candidates which is undated but the publication date of some texts was 1976, so it was prepared after that year. Personal Papers Dr John Shepherd.
270 contributions to the study of the ageing process.92 On a more mundane level the gradual development of the field of ‘care of the aged’ over the previous twenty years had produced some reports and local texts, in particular, The Aged in Australian Society, a compilation of papers published in 1970, and Growing Old, Problems of Old Age in Australian Society.93 The latter was published a decade earlier and it was also a collection of contributions to a seminar on the elderly.94 This problem and service oriented ‘social gerontology’ was represented in the written assessment through a research project in which candidates were allocated a section of a common topic selected by the supervising committee, such as for example, ‘Planning for Ageing Australians’.
The clinical skills relevant to geriatric medicine were found in a combination of psychiatric and general medicine texts. British contributions predominated in both areas. The texts chosen for the reading list for the Diploma program included Brocklehurst’s edited work, The Textbook of Geriatric Medicine and Gerontology, Ferguson Anderson’s Practical Management of the Elderly, Brocklehurst and Hanley’s, Geriatric Medicine for Students, Hodkinson’s An Outline of Geriatrics. 95 These texts reflected the work done by British physicians in adapting the concepts of general medicine to the elderly patient at risk of needing custodial care. Their pragmatic approach produced the handbooks characteristic of geriatric medicine, in which developments in the various specialties of general medicine and surgery were aligned with the degenerative conditions that contributed to the multiple disease conditions characteristic of the geriatric patient. British developments in psychiatry were also predominant. In the texts recommended for Diploma candidates the use of the term ‘psycho-geriatrics’ showed the extent to which psychiatrists there had developed specialist knowledge related to the topic
92 For details of Everitt’s career see Chapter Five. 93 The surveys included: NSW Consultative Committee, ‘The Care of the Aged’, 1965, F. Ehrlich, R. V. Horn, & S. Sax, ‘The Demography of Disability – An Australian Example’, NSW Department of Public Health and Council of Social Services of New South Wales, 1969, F. Ehrlich, ‘Chronic Illness in NSW – Needs and Services – a Demographic Approach’, Health Commission of New South Wales. S. Sax The Aged in Australian Society, Angus & Robertson, Sydney, 1970, A. Stoller, ed, Growing Old In Australia, Cheshire, Melbourne, 1960. 94 See Chapter Four. 95 This list of texts is taken from the undated copy of the reading list noted above. The rehabilitation text was F. H. Krusen, F. J. Kottke, & P. M. Ellwood, Handbook of Physical Medicine and Rehabilitation, W. B. Saunders Co, Philadelphia, latest edition.
271 of mental illness in old age since the mid-1940s when their attention had turned to the mental disorders of old age.96
The desire on the part of the Hospitals and Charities Commission to ensure that geriatric medicine in Victoria was confined to the provision of non- acute medical services was reinforced by the selection of institutions accredited to provide training posts. The Geriatric Hospitals, or Centres as many of them were now known, were the principal institutions. Others included Willsmere Psychiatric Hospital, the Geriatric Division of Caulfield Hospital, the Repatriation General Hospital at Heidelberg and Montefiore Homes, one of the largest voluntary agency institutions.97 The common element amongst these institutions, in relation to the Diploma course, was the provision of non-acute care and rehabilitation services. The overall effect of the introduction of the Diploma program, in highlighting the emergence of a class of institution or services devoted to the needs of the geriatric patient, was to emphasise the non acute aspect of this patient’s care.98 In this respect the objective of the Hospitals and Charities Commission was achieved. Doctors were trained to manage the needs of infirm old people from an institutional base outside the acute care system.
Nevertheless the question of whether geriatricians would provide medical services during an acute phase of illness persisted in the minds of the medical practitioners involved in the training program. It has already been noted that in developing this program, Malcolm Scott had emphasised the
96 The recommended texts were as follows, B. Pitt, Psychogeriatrics, Churchill Livingstone, 1974, L. Bellak, & T. B. Karasu, Geriatric Psychiatry, Grune & Stratton Inc., London, 1976. 97 Minutes Meeting Victorian Postgraduate Geriatric Medical Training Program, 17/2/75, 2/2/76, Personal Papers Dr. John Shepherd. 98 The problem with including Willsmere Hospital amongst the institutions suitable for training posts for Diploma candidates, was that it was under the control of the Mental Health Authority, a separate administrative body from the Hospitals and Charities Commission that supervised most of the institutions involved in this program. The Mental Health Authority had no structure for paying candidates not employed by it, Minutes Meeting Medical Superintendents, Managers and HCC, 11/12/74. In the mid-1970s the Repatriation Hospital provided fertile ground for the development of geriatric medicine because the ex-service personnel for whom the hospital was intended were ageing. However instead of promoting geriatric medicine, the hospital administration responded to this trend by taking steps to open the hospital to civilian patients to ensure variety in cases for the purposes of medical education and practice. The involvement of the Repat with the Diploma program, which may, in these circumstances, have been short-lived, is not mentioned in the most recent history of the hospital although the introduction of geriatric services in the 1980s is recorded as a prominent step in the development of the field of geriatric medicine, Hunter-Payne, op. cit. pp.95-103, p.164-165.
272 advantages of producing something that could be absorbed into either of the physician training programs developed by the Australian Association for Physical and Rehabilitation Medicine or the Australian Geriatrics Society. In light of R. B. Lefroy’s presence amongst the office holders of the Society, and his earlier definition of geriatric medicine as containing a component of acute care, it is likely any training program developed by the Society would include this element.99 On these grounds it may be assumed that provision was made in the Diploma program for the development of such clinical skills although there was limited chance of doing so in most of the accredited institutions.100 In fact there was an element of acute care in the services provided from the Geriatric Hospitals because they were aimed at the needs of patients who were neglected in existing hospital services. As Boyne Russell made clear in her report on the pilot geriatric service at Mount Royal, old people could be acutely ill, beyond the point of being cared for by a general practitioner, and still not be recognised as such by the public hospitals. Even in the case where the old person in ‘trouble’ had the hospital insurance that permitted prompt admission to a private hospital, their symptoms might not be correctly interpreted.
It was as a result of steps taken by a member of Mount Royal Committee of Management that the possibility of developing the acute care component of geriatric medicine received more prominence. When John Shepherd returned from an overseas tour in the early 1970s, he made a number of recommendations to his committee of management, including the establishment of a Professorial Chair in Geriatric Medicine. At the time he had no expectation that this suggestion would amount to anything. However, one member of the committee was not prepared to let the matter go, and, in Shepherd’s words, ‘he knew a lot of people and he pushed and pushed and before long we were talking to the Vice-Chancellor’ (of the
99 Lefroy, 1966, op. cit. pp.204-210. 100 Dr Leslie Wilson, a visiting physician geriatrician from Aberdeen, was present at one of the meetings where the Diploma program was under discussion. When asked for his opinion, he expressed the view that as the program was structured it would be best located in a geriatric department of a general hospital, VPRS 4523/P2/1010/1973-170, meeting 13/3/74.
273 University of Melbourne).101 A letter from the Vice-Chancellor to the President of Mount Royal committee dated 1972 suggests that discussions between the two institutions had started soon after Shepherd made his suggestion.102
Even at this early stage it was clear that any relationship between the University and Mount Royal was not going to be an easy one. The President of the committee of management initiated correspondence in a letter outlining the committee’s plans for establishing a research unit for the study of gerontology. There is no indication that the committee explored the possible meanings of this term. The Vice-Chancellor replied that while the University would not be able to contribute financially, it would consider the possibility of Mount Royal becoming an affiliated institution for teaching purposes once the unit was established. Furthermore, it would be happy to have representatives of Mount Royal on any committee to select the Director of such a unit. The Mount Royal committee was probably taken aback at being relegated to a secondary position in this peremptory manner. It may have been their response along these lines at a meeting in November of that year, between them, the Victorian Minister for Health, and representatives of the University, that led the latter to propose a more distant relationship. In the event of a Director being appointed, the University agreed to recognise this person as lecturer and to provide one or two teaching periods in the medical course.103
Undaunted, it appears, by having to proceed alone, the Mount Royal committee continued with the project of establishing a research unit. It expected to raise $200,000 from donations and on this basis sought the cooperation of its long-time partner in developing the field of geriatrics, the Hospitals and Charities Commission, in guaranteeing the salary of the Director of the unit. The Commission’s response was that, in accordance with its responsibility for geriatrics defined as ‘care of the aged’, not gerontology, the study of the ageing process, it was only prepared to fund
101 Personal communication from Dr John Shepherd, 23/2/98. Possibly this Committee member was Mr. Lionel Adams as the minutes of the Institute committee for the meeting held on the 17/2/78, referring to Adams’ recent death, note that he ‘more than anyone else’ was responsible for establishing the Institute. 102 VPRS 6345/478/1625. 103 Ibid.
274 a position in which geriatrics, defined as ‘care of the aged’ was paramount. At the insistence of the Commission the title of the Director was to be ‘Director of Gerontology and Geriatrics’.104 Bolstered by support from the Commission and voluntary donors, the committee approached the Commonwealth Minister for Health. By this time a sub-committee had been formed to oversee the establishment of the institute to be known as the Mount Royal National Research Institute of Gerontology and Geriatrics.105 At this stage the University had a change of mind and indicated its willingness to play a part in the project although, at this time, January, 1974, there was no indication that the Director of the proposed Institute would occupy a Professorial Chair. Instead it would be left to the appointee to investigate the possibility of establishing a Chair of Gerontology, and in the interim this person would be granted Senior Associate affiliation with the University.106
The change of mind on the part of the Faculty of Medicine was, no doubt, stimulated by the recommendation made by the Universities Commission to the Federal Government, that funding be made available to groups setting up health services, particularly if they were sponsored by a
104 Ibid. 105 The members of the sub-committee were, Messers D. Don, L. Adams, T.N.D. Stevens, and Sir William Upjohn, all members of Mount Royal committee of management. Sir William, long retired from his prominent position as a member of the medical staff of the Royal Melbourne Hospital, was also a member of the committee of management of Greenvale Village Geriatrics Centre in its early days, and of the committee of management of the Royal Melbourne Hospital. Other members of the sub-committee were; A.J. McLellan, Hospitals and Charities Commission, Dr John (SJH) Shepherd, Medical Superintendent of Mount Royal and representatives of the University of Melbourne and the Faculty of Medicine – Sir Robert Blackwood, Professor David Derham and Professor Sir Lance Townsend. Minutes of Meetings of the Sub-Committee, Personal Papers Dr Shepherd. Sir Lance Townsend’s involvement is somewhat surprising in view of the conclusion reached in the report on the provision of hospital services in Victoria, of which he was one of the authors. The comment was made that while there was indeed a need for rehabilitation services to be provided as an extension to existing hospital services, there appeared to be little justification for making distinctions on the grounds of age. 106 Minutes Meeting of Institute Sub-Committee 24/1/74.
275 University.107 The more cooperative attitude on the part of the Faculty of Medicine certainly seems to follow the agreement in December, 1973, on the part of the Hospitals and Health Services Commission, to provide funding for activities at the proposed Institute at the rate of $30,000 for three years, providing such activities were confined to ‘clinical’ and ‘social gerontology’. Further enquiry on the part of the interim committee of the Institute, confirmed that the Directorate could use these funds for teaching purposes.108 Representatives of the University and the Faculty of Medicine, were, no doubt, induced to overcome a reluctance to enter into a cooperative venture with Mount Royal, by the advantages of participating in the venture without any financial outlay, while at the same time satisfying demands in relation to medical education in neglected areas. It was not just that the institution was ‘beyond the pale’ in respect to acceptable medical institutions. Its committee of management was unaccustomed to subordinating its will to any other body and fully intended retaining its status as proprietor of the new establishment.
Such an impressive array of support for ‘geriatrics and gerontology’ did not necessarily mean support for developing a medical specialty in geriatric medicine. The establishment of a research institute and a
107 The minutes of this first meeting of the sub-committee indicate that Professor Derham. Vice-Chancellor, had come to this conclusion from his reading of the report submitted by Committee on Medical Schools to the Universities Commission in 1973, Minutes Meeting 24/1/74. The Report noted, ‘It is necessary to evolve a new philosophy in respect of general practice in the medical curriculum’, to equip medical students better to deal with the problems of illness they were presented with in general practice. In this recommendation the Committee on Medical Schools coincided with the aims underpinning the Community Health Program - to encourage the organisation and provision of primary health services which emphasis prevention and rehabilitation, and to develop the epidemiological and social research to provide a body of knowledge to support this form of practice. The coincidence was not accidental; it arose out of cooperation between the Hospitals and Health Services Commission under the Chairmanship of Sidney Sax and the Universities Commission headed by Professor Karmel. A Department of Community Medicine was established at the University of Melbourne but it was not attached to any one Health Centre. In his report ‘Community Practice in Australian Medical Schools’, E. G. Saint, notes that an interest in establishing chairs in geriatric medicine was ‘a collateral’ development of the Community Health Program, and went on to comment, ‘It is hard to avoid taking a view that this interest has been opportunistic, a response to pressures exerted by affiliated hospitals or health departments in Commissions understandably anxious to give leadership in a neglected area of clinical medicine.’ Saint’s report was published in 1981 and he noted the poor result in this case, ‘Backup resources have been slender and integration of teaching with the department of community medicine is weak’, Saint, 1981, op. cit. p.14. 108 One of the first steps taken by the sub-committee was to apply to the Federal Minister for Health, the Hon. D. Everingham, for assistance with funding. In January 1974, the Chairman, Denzil Don noted correspondence from Sidney Sax, Chairman of the National Hospitals and Health Services Commission, dated December, 1973, setting out the details of this funding. Minutes Meeting Mount Royal National Research Institute of Gerontology and Geriatric Medicine Committee, 24/1/74.
276 professorial unit to provide clinical services did have the potential to support the development of geriatric medicine as a specialist medical field. However, a range of other interests were brought into play in this project, interests that were, in Victoria, more soundly established and powerful than the newly formed Australian Geriatrics Society. The Hospitals and Charities Commission was certainly prepared to do what it could to enhance the standing of ‘geriatric medicine’ as part of its responsibility for overseeing ‘care of the aged’ in the State, but not at the expense of its long-standing plan to limit the provision of such services to institutional settings outside the acute hospital system.
The Mount Royal Committee of Management was interested principally, in advancing the standing of the institution and ‘geriatrics’ meaning ‘care of the aged’. If this led to the promotion of any specific medical expertise, well and good, but the committee had shown no sign over the previous twenty-odd years, to set aside its interests in favour of advancing medical interests. In addition, although the Committee was, it appears, ready to take on ventures that might add to the stature of their institution, they did so in a manner that immediately limited the success of such ventures. This had been the case in their early collaboration with the Royal Melbourne Hospital in building and operating the first Geriatric Unit opened in 1957.109 The same attitudes of penny pinching and reluctance to relinquish control came to the fore in the case of the Institute. When Derek Prinsley, the English physician who was eventually appointed as Director of the Institute in 1976, took up his position he found, as he stated in his first report on the Institute, ‘no premises, no staff and no income’. Furthermore he was confronted by a committee of management which believed that ‘… a count of how many left and how many right hemiplegias were admitted was a suitable contribution to research in gerontology’.110 When he attempted to attend the Mount Royal Committee of Management meetings, as representative of the University, the Committee frustrated his efforts by not notifying him when meetings were held. Then, when called to account by the Hospitals and Charities
109 See Chapter Three. 110 D. M. Prinsley, ‘Biomedical Research Priorities at the National Research Institute of Gerontology and Geriatric Medicine’, Proceedings 19th Annual Conference Australian Association of Gerontology, 1984, pp.8-10.
277 Commission, cited a hospital by-law that a paid official of the hospital could not be a member of the Committee. Even when the Hospitals and Charities Commission countered this objection by pointing out that Prinsley had been appointed to the Committee, not elected, the Committee stood firm, citing legal opinion supporting its stance.111
The interest expressed by the Faculty of Medicine was most probably, as Eric Saint was later to describe it, ‘opportunistic’, not reflecting any genuine interest in cultivating the medical care of infirm old people.112 While the Faculty did encourage the introduction of lectures into the undergraduate program, it showed no interest in absorbing the Diploma of Geriatric Medicine into its revamped Master of Medicine course. The academic standard of the program may have provided cause for concern but that could have been improved in the process of being included in the Master’s degree had there been any genuine interest.113 The entry of the Hospitals and Health Services Commission into the field brought another line of interest that fed into local interests but not necessarily those who wished to promote geriatric medicine as a specialist field of medical practice. The Commission’s views were compatible with the desire of the committee of management of Mount Royal to preside over a prominent institution, and with the desire of the Hospitals and Charities Commission to establish geriatric medicine as a field of medical work outside the acute hospital.
The Hospitals and Health Services Commission had decided to foster expert medical and paramedical services for the infirm aged by promoting the development of a small number of Centres of Excellence around the country. This aim fed into the desire of the Mount Royal Committee of Management to maintain, what it believed was its prominent position in the field of geriatrics. It was also compatible with the desire of the Hospitals and Charities Commission to establish the practice of geriatric medicine outside the acute hospitals and in the form of rehabilitation treatment associated with coordinated welfare services. The Hospitals and Health Services Commission envisaged that, while Centres of Excellence
111 VPRS 4523/P2/8283. 112 Saint, 1981, op. cit. p.14. 113 Minutes Meeting Victorian Postgraduate Geriatric Medical Training Programme Committee, 28/7/80, 11/10/82.
278 would promote geriatrics, they would operate principally as educational and research resources for community health services. In keeping with this objective the grant to the proposed Mount Royal Research Institute from the Commission was intended to foster the provision of services, not for studies of the ageing process.
It is clear that this was well understood by Victorians who were interested in research in ageing. In February 1976 a symposium was held in the Microbiology School at the University of Melbourne to discuss the development of biological research into ageing, but there appears to have been no expectation that the proposed Research Institute at Mount Royal would be involved.114 The research at Centres of Excellence would serve to establish standards of service for the aged and infirm, and generally foster the development and coordination of services for them throughout a specific area. Although these Centres were intended to be ‘clearing houses’ for the latest developments in geriatric medicine, their primary role was not to promote this specialty, but to provide a means of dispersing the knowledge associated with it. For this reason the Commission regarded the establishment of Chairs of Geriatrics in Universities as undesirable – isolating geriatric medicine in this fashion would diminish the effective spread of the ‘gospel’ of geriatrics – care of the aged.115
R.B. Lefroy, President of the Australian Geriatrics Society protested at this representation of geriatrics. In a letter to Professor Karmel, Chairman of the Australian Universities Commission, the body concerned with promoting education in geriatrics for medical practitioners, he claimed the document that had come from the Hospitals and Health Services Commission to assist the Universities Commission, was ‘erroneous and
114 MacKay, op. cit. 1977. Dr Ian MacKay was a member of the Committee of Mount Royal National Research Institute for Geriatric Medicine and Gerontology, and, at the same time, Director of the Clinical Research Unit at the Royal Melbourne Hospital and the Walter and Eliza Hall Institute, a situation in which he could have experienced a conflict of interests. 115 Draft copy, ‘Geriatrics in Health Personnel Education’ Hospitals and Health Services Commission, Archives Australian Society for Geriatric Medicine.
279 misleading’, in representing geriatrics as ‘“basically the provision of Community Health Services for the elderly”’.116 The recommendation that the appointment of a lecturer in geriatrics to Departments of Community Practice would be a satisfactory means of training doctors for work in caring for the ‘elderly and disabled’, Lefroy pointed out, meant that the medical care of this group remained outside the mainstream of medical work – the teaching hospital. The creation of ‘Centres of Excellence’ would reinforce both the existing isolation of geriatric medicine from general medicine, and the view that it was principally concerned with a form of community based welfare services.117 The lack of response to Lefroy’s letter indicates how little the advocates of geriatric medicine contributed to the process in which the new order of hospital and health services was constructed.
Lefroy concluded his letter by reiterating the Society’s ‘strong’ support for Chairs in Geriatric Medicine. The Society was, however, not involved in the events that led to the establishment of the first such Chair in Australia, at Mount Royal. This situation illustrates not only the extent to which the Society had yet to establish itself as an authority, but also the degree to which the promoters of the Chair saw no connection between their actions and the promotion of a specialist field of medical work. The first advertisement for the position of Director of the proposed Mount Royal National Research Institute of Gerontology and Geriatrics failed to result in an appointment.118 David Wallace, the physician who first took on the task of developing a geriatric unit at Greenvale Village in the late fifties was one of two local applicants, neither of whom was appointed. In view of the emphasis the HCC placed on the management of a geriatric service in supporting this appointment, it was quite likely that lack of experience in managing a geriatric service accounted for this. Sidney Sax, in
116 Letter dated 14/5/76 from Professor R. B. Lefroy, President of the Australian Geriatrics Society to Professor Karmel, Chairman Universities Commission, Archives Australian Society for Geriatric Medicine. 117 Ibid. 118 The minutes of a meeting of a special committee to consider applicants for the position of Director indicate that six enquires were received from the United Kingdom, one from New Zealand. Minutes of Meeting of Selection Committee, 15/7/74. The selection committee consisted of four representatives from Mount Royal – the President of the Committee of Management, Denzil Don, committee member, L. Adams, M.E. Atkinson, Manager, Dr John Shepherd, Medical Superintendent, university representatives are not listed but may have included Professor Pennington and Professor Sir Lance Townsend, Letter, 5/6/74 from M.E. Atkinson, Manager, Mount Royal to Professor David Derham.
280 providing a reference for one of these candidates reinforced the Commission’s view when he emphasised the difference between the practice of geriatric medicine (the provision of specific services) and the practice of medicine among elderly people.119
It is likely that suitable candidates from overseas were deterred by the lowly position of the Director in relation to the University because in February, 1975, the interim committee of Mount Royal Institute for Gerontology and Geriatric Medicine met to discuss a letter from the University advising that the Council had passed legislation providing for the appointment of the Institute Director as Professor of Gerontology and Geriatric Medicine.120 Shortly after, an advertisement was drafted inviting applications from persons ‘with Postgraduate Medical qualifications in physical and social medicine’, with senior research experience, and qualified to carry out clinical teaching. It may be concluded, in view of David Race’s association between social medicine and the provision and coordination of welfare services to enable infirm, elderly people to remain living in their homes rather than be admitted to institutional care, that in the advertisement, the term referred to experience in supervising a geriatric services. Derek Prinsley, the English consultant in geriatric medicine who took up the appointment as Director and Foundation Professor of Gerontology and Geriatric Medicine. in July, 1976, certainly had experience in administering a geriatric service and in this respect would have suited the Commission’s requirements.121
By the time Professor Prinsley arrived to take up his position, the facilities of Mount Royal had been separated into several divisions, each
119 David Wallace, at the time of his application was a physician at the Royal Newcastle Hospital in New South Wales. The other candidate was Dr Ian Webster, a Melbourne trained doctor and honorary physician at Royal Prince Alfred Hospital in Sydney. Webster’s interest in old age was exhibited by reference to a joint paper with Arthur Everitt, the physiologist working on the ageing process in rats, on the topic of ageing and breathing, at the meeting of the International Association of Gerontology in Leningrad. Webster was later appointed Professor of Community Medicine at the University of New South Wales, from Personal Papers Dr John Shepherd. 120 Leslie Wilson, the physician geriatrician from Aberdeen, who had given his opinion on the Diploma Program, was also asked for an opinion regarding the position of Director of the new Institute. He wrote back saying that the individuals he had spoken to regarding the position as it was first envisaged, had said it had ‘too indefinite a University role’ in their opinion, Minutes Meeting Institute Committee, 4/2/75. 121 Professor Prinsley was appointed consultant in geriatric medicine to Teesside Hospitals, in the United Kingdom in 1959 and held this position until his appointment at Mount Royal.
281 responsible for providing geriatric services to a specific municipal area within the region allocated to the hospital.122 One of these divisions became a Professorial Unit under Prinsley’s direction. His appointment encouraged the Acting Executive Director of the Royal Melbourne Hospital to propose an affiliation between Mount Royal and the Royal Melbourne at the beginning of 1977. While the participants may not have been aware of the fact, this was a revival of a relationship, not an innovation. The coooperative relationship between the two institutions was an element in the development of the first purpose-built geriatric unit at Mount Royal in 1957.123 The arrangement gave the physician geriatrician a consultative role in the acute hospital but there was no question that the geriatrician occupied a position similar to the other physicians attached to the Royal Melbourne.124
Late in 1976, the Royal Australasian College of Physicians agreed to award its Fellowship to physicians who completed the advanced training in geriatric medicine developed by the Australian Geriatrics Society.125 The appointment of Derek Prinsley as Foundation Professor of Gerontology and Geriatric Medicine was then also linked to the broadening of possibilities in training in geriatric medicine in Victoria.126 The Hospitals and Charities Commission responded by creating registrar positions at Mount Royal, similar to those already created under Malcolm
122 Annual Report Mount Royal, 1977. This must not be taken to mean that Mount Royal had established facilities of an acceptable standard. In 1974 the hospital had to restrict admissions because staff would not work in the overcrowded wards, VPRS 4523/P2/381/7- 105. 123 See Chapter Three. The coordinating committee established when the purpose-built geriatric unit was opened in the late 1950s, continued to meet at least until the end of 1969. Present, at what may have been the last meeting in December, 1969, were Drs Sinclair and Jamieson representing the Royal Melbourne, and Drs Shepherd and Butterworth and the Manager of Mount Royal, Mr. M.E. Atkinson, RMH Archives/Medical Matters/No 1/24/1969. 124 VPRS 4523/P2/381/7-105. In 1985, Prinsley, and M.C. Woodward, then a trainee in geriatric medicine, described this relationship at a meeting of the Australian Association of Gerontology, M.C. Woodward, D.M. Prinsley, ‘A Model of Geriatric Services in Acute Hospitals: The Royal Melbourne Hospital-Mount Royal Hospital Inter-Relationship’, Proceedings 20th Annual Conference, Australian Association of Gerontology, 1985, pp.65- 67. 125 This did not mean that the Australian Geriatrics Society wanted to take on an accrediting role – while the Society promoted its training program as a means of acquiring specialist skills in geriatric medicine, it was still possible for any medical practitioner granted Fellowship of the Royal Australasian College of Physicians to work as a geriatrician. The idea underpinning this approach was to maintain as close a connection as possible between general medicine and geriatric medicine, Lefroy, op. cit. 1988, p.71. 126 Prinsley himself was not aware that this was possible, finding out only when R.B. Lefroy wrote on behalf of the Australian Geriatrics Society, to welcome him, Archives Australian Society for Geriatric Medicine, General Correspondence File.
282 Scott at Mt Eliza and at Caulfield, under Bruce Ford – both of whom were advocates of broader rehabilitation medicine.127 The link between Prinsley’s appointment and the revival of the association between the Royal Melbourne and Mount Royal, and the introduction of registrar training positions into Mount Royal, obscures the point that Boyne Russell, a qualified and experienced physician in geriatric medicine, had been on the staff of Mount Royal since 1972. Since she had established a geriatric service in the form of the Brunswick Community Care Program in 1973, she was also in a position of being able to supervise a registrar in a self-contained and comprehensive service and capable of interacting with Royal Melbourne medical staff on equal terms. Any answer to the question of why Russell appears to have been overlooked must, regardless of other factors, also include gender – being female in the male dominated world of the Commission, the Royal Melbourne medical staff, the Faculty of Medicine and the Committee of Management of Mount Royal ensured invisibility.128
The question of what form of expertise would be developed by the physician-geriatricians trained at Mount Royal has already been answered to some extent. David Race, Chief Clinical officer in the Hospitals and Charities Commission was consistent in his refusal to agree to the provision of acute care in the geriatric services. However, as noted above, because these services were directed towards the needs of elderly patients neglected within general hospital services but who were often acutely ill, a certain element of acute care provision was inevitable. No doubt Derek Prinsley expected his work to include acute care as he had come from a hospital system where such provision was part of the work of the geriatric department. In a report compiled during his first six months at Mount Royal he noted that his position could be divided into three separate elements, of which ‘clinical medicine’ was one. There must have been sufficient doubt relating to the provision of short-term care in acute illness amongst Victorian geriatricians, because at a meeting of Medical
127 Ford and Scott were both founder members of the Australian College of Rehabilitation Medicine which replaced the Australian Association of Physical Medicine and Rehabilitation. The inaugural meeting was held in 1980. 128 Russell’s teaching ability and her overall contribution to geriatric medicine were recognised on her retirement from Mount Royal after twenty years, when she was offered honorary life membership of the Society, Australian Society for Geriatric Medicine Archives/General Correspondence File/Letter dated 26/2/93.
283 Superintendents and Managers of the Metropolitan Geriatric Centres, in July 1978, Malcolm Scott asked for clarification of this point. David Race, consistent as ever, replied that the ‘hospital’ beds in the geriatric centres were intended for ‘assessment and the development of treatment plans, not for the treatment of acute illnesses’.129 Notwithstanding the Commission’s views, the annual report for Mount Royal for 1978 noted the opening of a 24-hour medical centre equipped with X-ray facilities. However even if Mount Royal was exceptional in the extent of acute care it provided, this still fitted the role the Hospitals and Health Services Commission had designated for it as a Centre of Excellence.
The training program established by the Australian Geriatrics Society reflected the range of opinion within the Society as to what form geriatric medicine could take. An approved training post needed to provide experiences in Geriatric Medicine, Rehabilitation, Community Care and General Medicine as core training with experience in two of three areas – General Medicine, Neurology, Psychiatry or Psychogeriatrics. It is interesting to note that while there was room for some flexibility in relation to training posts suitable for core training, the essential components necessary for a training post to be approved, were Domiciliary Consultations, Multi-disciplinary assessment and care, Medical Rehabilitation, Home Care and Permanent Care.130 Mount Royal satisfied most of these requirements, and in the early 1980s, the addition of a psychogeriatric unit extended the possibilities available to trainee physicians.131 Regardless of the clinical experience available at Mount Royal, the positions open to graduates in the other Geriatric Centres ensured that, on the whole, the practice of geriatric medicine would be as
129 VPRS 6345/578/78/941, op. cit., and Minutes Meeting Medical Superintendents and Managers of Metropolitan Geriatric Centres and Hospitals and Charities Commission, 14/6/78. 130 From notes sent by the Australian Geriatrics Society to the Chairman of the National Specialist Qualification Advisory Committee, undated, Archives Australian Society for Geriatric Medicine. 131 The establishment of this unit did not represent any coordination between the Geriatric Hospital and psychiatric services. It was a step taken by Mount Royal Hospital, in the same independent manner in which most hospitals established their services and its desirability was questioned by the Directors of both the Hospitals and the Mental Health Divisions in the Victorian Health Commission which had, by then taken over the responsibilities of the various authorities, including the Hospitals and Charities Commission, that supervised the provision of hospital services, VPRS 6345/111/1592.
284 David Race had planned. None of the other geriatric centres, new or old, had a close association with a teaching hospital. While they were all situated in a regional relationship with these institutions, the geriatrician was confined to the provision of the assessment and rehabilitation services as first envisaged by the Hospitals and Health Services Commission in the mid 1950s.
The beginning of the 1980s in Victoria saw the emergence of geriatric medicine as a special interest available to medical practitioners at the level of general practice or consultant physician. General practitioners were able to cultivate a special interest in geriatrics through the Diploma of Geriatric Medicine and the Family Medicine Program supervised by the Victorian Faculty of the Royal Australian College of General Practitioners. Increasing competition for postgraduate training positions amongst medical graduates, and exposure to the influence of physicians such as Prinsley and Russell, led a small number of doctors to include the training program developed by the Australian Geriatrics Society in their physician training. By the early 1980s four physicians had qualified as geriatrician physicians and 17 doctors had graduated from the Diploma in Geriatric Medicine program.132
While physicians were generally younger doctors at the beginning of their careers, Diplomates were a mixed group. The range of ages in candidates – from the twenties to the late fifties and early sixties – suggests the course represented a variety of different possibilities to candidates.133 Lack of evidence in this matter precludes any detailed comment. What can be said is that the course seems to have provided an opportunity for doctors well on in their careers to change direction, a characteristic common to the doctors who first took on the role of geriatrician in the late 1950s and early 1960s. The Diploma program also provided a career path for women doctors who had been unable to follow their male colleagues along the usual routes of either specialist training or general practice because of other commitments. They used the Diploma to gain access to the positions
132 Annual Report Mount Royal, 1981, 1982. 133 The breakdown of age groups shows throughout the first ten years: in the age group 21- 30, 23 began the course and 13 Diplomas awarded, 31-40, 27 began and 9 Diplomas, 41-50 years, 17 began and 9 Diplomas, 51-60, 13 began, 6 Diplomas, 60+, 2 began and 1 Diploma awarded, Minutes Training Committee Meeting, 27/2/85.
285 the Hospitals and Charities Commission created in the geriatric services, or as regional geriatricians or in some cases, as a stepping stone to specialist physician training either in general medicine or psychiatry.134 Doctors from overseas also benefited from the extension of medical work in the provision of geriatric services both as geriatricians in the institutional setting and as regional geriatricians.135
Conclusion In the decade between 1972 and the early 1980s the recipient of benevolent care, the ‘old person in trouble’, underwent the final stages of a process of redefinition that had begun in the late 1950s, when the first attempt was made to introduce geriatric services into Victoria’ s hospital system. The appearance of the ‘sick man’ in the work of geriatricians at the end of the 1970s, marked the emergence of a specialist field of medical practice defined in terms of health and illness in old age. The formal status of the first locally trained physician geriatricians who qualified in the early 1980s was quite explicit. They had completed a training program developed by the Australian Geriatrics Society and recognised by the Royal Australasian College of Physicians. The physician geriatrician was included in the listing of medical specialties published by the Commonwealth Department of Health in 1977, and a few years later in 1984, in a local publication put out by the Victorian Medical Postgraduate Foundation.136
The notion of sickness associated with the work of physician geriatricians was, on one level no different from that of other medical practitioners, it was associated with a disturbance in physiology that was amenable to the
134 These positions would have been even more attractive when equal pay for women doctors was introduced into State Public Service and all public hospitals in the late 1960s or early 1970s. The Commonwealth made this move somewhat later, E. Sandford Morgan, A Short History of Medical Women in Australia, no publisher, no date, p.48. In Victoria, the report presented by J.V. Dillon in 1959, on the terms and conditions of doctors’ employment in the State’s hospitals, recommended equal pay for women doctors. 135 Personal communication from Mrs Marion Shaw, March, 1997. 136 Commonwealth Department of Health, Handbook on Health Manpower, Part 2, Australian Government Publishing Services, 1977, p.36. In this publication the occupations of medical practitioners were divided according to whether they were associated with a recognised post-basic course of training. Occupations that were, were designated as medical specialists, p.20. Geriatric medicine was also listed as a sub- specialty of internal medicine in a publication of the Victorian Medical Postgraduate Foundation, Medical Careers in Australia, 1984, p.38.
286 same diagnostic methods used in other patients. At this level the difference lay in the attitude of the doctors involved who were prepared to pay attention to a group of patients who were not only of little interest to other hospital specialists, but who were likely to have been made sick by the treatment they were given. On another level, however, this notion of sickness differed from the conventional one in that it was associated with a more ambiguous measure of success - the restoration of social competence within limits that were set by the individual, rather than cure associated with the establishment of a physiological norm. It was only when patients did not respond to conventional medical treatment or when their social competence was threatened, that their ‘sickness’ brought them within the purview of the physician geriatrician.
This notion of ‘sickness’ was inherently unstable because it was tied to a model of medical practice that was unsuitable for the needs of a certain group of elderly people. In theory, as physician geriatricians exerted more influence on medical training and overall practices changed, the need for this role could disappear. However, in Victoria in the early 1980s when the first locally trained physician geriatricians took up their positions, this situation was far from sight, the instability of this notion of ‘sickness’ was associated with the social and professional conditions in which they were situated. Mount Royal Hospital was an exception amongst the Geriatric Hospitals in its close association with a general hospital. In the absence of strong medical leadership in directing the line of development of geriatric medicine, other influences had free play. Amongst these were the Hospitals and Charities Commission, which sought to establish geriatric services as complementary to acute care services, not as part of them. From the perspective encouraged by the Commission, it was not so much the ‘sick man’ who was the focus of the geriatrician’s attention, but the ‘dependent old lady’ described by Bruce Ford, medical rehabilitationist. Doctors in the other Geriatric Hospitals also treated old people who were acutely ill, but only because these patients were unwanted anywhere else. This aspect of their role was unofficial and related to the inefficient functioning of the hospital system.
As far as the broader community was concerned, the notion of sickness that geriatricians sought to establish was obscured amidst a growing
287 provision of nursing home beds. The Federal government had attempted to impose restrictions on this apparently inexorable demand. By the late 1970s, the number of nursing home beds provided in the Geriatric Hospitals had decreased, but those provided by the voluntary agencies and private businesses had increased. Reluctance on the part of other medical practitioners to acknowledge even the limited role of the geriatrician in providing restorative treatment, ensured that the community as a whole, continued to emphasise the provision of beds, not the provision of services. Even when members of the community were aware of what a Geriatric Service had to offer, as Boyne Russell found, they were not always appreciative of the possibilities offered by the redefinition of old age infirmity as ‘sickness’.137
137 Russell, 1977, op. cit. p.111.
288 CHAPTER 7 MEDICINE OF SENESCENCE OR MANAGING THE SYSTEM?
In this thesis I wanted to identify the conditions that made it possible for medical practitioners in Victoria to establish a specialist field of practice defined in terms of health and illness in old age. My aim was to clarify the process of specialisation within medicine in Victoria and to identify what this process can tell us about the public understanding of old age. The purpose of this final chapter is to assess the interactions between ideas, interests and social structures in which the emergence of the specialty of geriatric medicine was embedded, in relation to this objective. The chapter is divided into two sections. The first examines the integration of geriatric medicine into the professional and institutional environment in which hospital services were provided in Victoria. The second section examines how defining a specialist field of medical practice in relation to health and illness in old age shaped the public understanding of old age.
The specialty of geriatric medicine emerged out of the activities of diverse groups. Amidst a growing clinical engagement with diseases associated with increasing age, a segment of the Australian medical profession sought to establish an orientation and organisation of medical practice to deal with problems of illness and disability they thought were neglected within the existing focus on personal, curative medical services. The Victorian government bureaucracy responsible for the organisation of hospital services acted to ensure the most efficient use of public funds in an environment where autonomous, local committees of management provided publicly funded hospital and welfare services. The Federal government also sought to control a growing expenditure on age-specific hospital and welfare provisions, the result of ad-hoc decisions taken to deal with the exigencies arising in the course of managing the system of national, publicly subsidised, voluntary hospital insurance introduced in the early 1950s. At the local level, a small band of medical practitioners sought to integrate their work in the geriatric hospitals with mainstream medical practice as their respective committees of management maintained and augmented a century-long tradition of providing care for aged Victorians. During this period elderly Victorians, defined as such on
289 the basis of age of eligibility for the Age Pension, became more visible in a population enlarged by a higher postwar birthrate and immigration.
Specialists in Name Only Integration When the first locally trained physician geriatricians qualified in the early 1980s, their formal status as specialists was quite explicit. This formal status however did not reflect any degree of integration into mainstream medicine in Victoria, and this was one of the tasks that confronted them. At the national level, as R.B. Lefroy, one of the principal actors in promoting geriatric medicine, noted, the association between the Australian Geriatrics Society and the College marked the beginning of an integrative process, not an endpoint.1 Possibly the College was more disposed to view the Society’s proposal favourably because the ground had already been prepared in the earlier efforts of the Australian Association for Physical Medicine and Rehabilitation to gain College recognition for a training program in a socio-medical field of practice. Recognition of the specialty of rehabilitation medicine certainly appears to have had more significance in the history of the College. The appointment of a Specialist Advisory Committee on Rehabilitation Medicine is listed amongst the events that were significant in the life of the College for 1975, whereas the appointment of a similar committee in relation to geriatric medicine shortly after, passed unremarked.2
Rehabilitation medicine was given more prominence because the doctors who promoted it operated from a long-standing organisational base. Where the Australian Geriatrics Society had only been in existence for a few years when its members applied for College recognition, the Association for Physical Medicine and Rehabilitation, which applied around the same time, had been in existence since the mid-1940s. The Diploma course supervised by this Association, in cooperation with the Postgraduate Medical Association, had been available for some years.3 The advocates of rehabilitation medicine were thus in a much better
1Lefroy, 1988, op. cit. p.71. 2 R. Winton, Why the Pomegranate? A History of the Royal Australasian College of Physicians, The Royal Australasian College of Physicians, Sydney, 1988, p.48. 3 See Chapters Two and Five for the Australian Association for Physical Medicine and Rehabilitation. The Australian Geriatrics Society is now known as the Australian Society for Geriatric Medicine.
290 position to play a part in the policy-forming activities of the short-lived National Hospitals and Health Services Commission in the years between 1973 and 1975, when the first funding programs were introduced to support medico-social hospital services. The efforts of the medical rehabilitationists were reinforced by the recommendations of the Woodhouse Committee of Inquiry into compensation and rehabilitation which reported in 1974.4 The advocates of geriatric medicine on the other hand, played little or no part in the policy-making of the mid 1970s. In these circumstances geriatric medicine was seen as a subsidiary activity within the broad field of medical rehabilitation and as an element in community medicine concerned with the provision of welfare measures. While this outcome did not reflect the ideas of those geriatricians who emphasised the provision of acute hospital services as a component in geriatric services, it was not altogether contrary to the wishes of some of their colleagues. When Sidney Sax defined geriatric medicine as the provision of age-specific rehabilitation services in the mid-1960s, in a lecture to postgraduate nurses at Concord Repatriation Hospital in New South Wales, he was most certainly describing the form of practice being developed (albeit slowly) in this environment.5 The adoption of a broad definition of geriatric medicine by the founders of the Australian Geriatrics Society accommodated the variations in work settings of geriatricians.
When the first locally trained physician geriatricians began to establish themselves in Victoria early in the 1980s, it was already clear that some of their colleagues were beginning to make their way along the path set for them by funding for rehabilitation medicine and community medicine programs. At the end of the 1970s the Association for Physical Medicine and Rehabilitation was transformed into the Australian College of Rehabilitation. Malcolm Scott was a founding member of the College and in 1978 he was nominated as liaison officer in relation to medical rehabilitation, between the Commonwealth and the Victorian government.6 Scott, a physician, whose early interest in rehabilitation had
4 Report of the National Committee of Inquiry, Compensation and Rehabilitation in Australian, Chairman, Mr Justice W.O. Woodhouse, Australian Government Publishing Service, 1974, p.222. 5 Sax, 1965, op. cit. 6 VPRS 6345/64/X1091/7 and VPRS 6345/555/2381.
291 led him to become involved in rehabilitation services at the Heidelberg Repatriation Hospital, had worked hard to establish geriatric services according to the lines laid down by the Hospitals and Charities Commission in Victoria, first at Greenvale and then at Mount Eliza. In 1983, Gary Andrews was retiring president of the College. Having completed his physician training in geriatric medicine under Professor W.F. Anderson in Glasgow in the late 1960s, he returned to New South Wales and took up the position of medical superintendent at Lidcombe Hospital. He became first president of the Australian Geriatrics Society when it was formed in 1972. At the time he delivered his presidential address in 1983 he held the position of Professor of Community Medicine at the University of New South Wales.7
The tendency, at the national level, to emphasise the rehabilitation and community-based services components of geriatric medicine coincided with the aims of the Hospitals and Charities Commission in Victoria in its support for geriatric services. However, the first locally trained physician geriatricians in Victoria were exposed to a somewhat broader experience. Under the tutelage of Derek Prinsley and Boyne Russell, they were introduced to the clinical skills developed by British physicians to treat patients who did not readily fit the template of clinical work in the acute hospitals. It was a form of training in which the link between geriatric medicine and general medicine was quite clear. In a medicine developed around a ‘norm’ of physiological function, the clinical skills of the physician geriatrician lay in that practitioner’s openness to dealing with a norm that was ‘neither a matter of semantics nor statistics, but a burning issue to be decided afresh at every clinical intervention’.8 Prinsley’s formulation of the clinical skills of the geriatrician as the capacity, ‘to see the sick man in the old person in trouble’, encapsulated a clinical perspective that had been shaped, not so much by the specific character of illness in the aged person, as by the limitations of a view of disease as a specific lesion in a specific organ or bodily system.
7 Proceedings of the Third Scientific Meeting, 1983, The Australian College of Rehabilitation Medicine, 1983. 8 Quoted in D. Armstrong, The Political Anatomy of the Body, Medical Knowledge in Britain in the Twentieth Century, Cambridge University Press, Cambridge, 1983, p.91-92.
292 ‘Trouble’ in the sense of Prinsley’s phrase could, and often did, involve an element of poverty and the neglect that saw old people’s infirmities accounted for by ‘old age’. In 1970s Victoria however, it was just as likely to mean exclusion from medical treatment because of anticipated problems in discharge, and the introduction of a form of universal hospital and medical insurance did nothing to change this situation.9 ‘Trouble’ might also mean that the hospital doctor or general practitioner did not recognise illness in the signs and symptoms presented by an elderly person. It also took the form of medically induced illness arising from the effect of commonly used pharmaceutical therapies on an aged physiology. Under the influence of the English-trained physicians at Mount Royal, who also had access to the acute wards of the Royal Melbourne Hospital, a form of geriatric medicine emerged which promised to address the needs of that group of elderly patients G.V. Davies had identified in the early 1960s – a group that Boyne Russell brought to light once again in the mid- 1970s, in her report on the Brunswick Community Care Program.10
An optimistic view of the position of geriatric medicine in Victoria, around the end of the 1970s, suggests that for a brief moment there may have been an opportunity to integrate geriatric services with those provided in the acute hospitals. After all, it was owing to the entrepreneurial approach taken by the Victorian medical profession, in cooperation with hospital committees of management, that hospital services had developed in the form they had. The Hospitals and Charities Commission had been consistent in the view that geriatric services should be an extra-mural appendage to acute hospital services. There was however sufficient ambiguity in the Commission’s attitude that, combined with the spark of interest that the appointment of Derek Prinsley provoked,
9 A principal element in the reforms related to health services introduced by the Whitlam government, was the establishment of the Health Insurance Commission in 1975 and the first form of Medibank, a universal, publicly funded hospital and medical insurance scheme. Aged Pensioners were, for the first time, treated in the same fashion as other adults, being eligible for services provided by general practitioners and specialists, R.B. Scotton & C.R. Macdonald, The Making of Medibank, Australian Studies in Health Service Administration, no 76, School of Health Services Management, University of New South Wales, Kensington. Old people who did not respond to hospital admission in the same fashion as younger adults were no more welcome under this system. 10 Davies, 1961, op. cit; Russell, 1976, op. cit.
293 the opportunity may have existed to establish a close link between the practice of geriatric medicine and general medicine in the acute hospitals. The Royal Melbourne was not the only teaching hospital that expressed interest in the services of the physician geriatrician. The Queen Victoria Hospital did also, as did St Vincent’s hospital.11 The latter, somewhat unusually for the metropolitan teaching hospitals, already had a purpose- built rehabilitation wing and home care service. The former had been funded by the Hospitals and Charities Commission although the hospital had not requested such facilities and the latter had been established by hospital administrators of their own volition, to meet patients’ needs.12
Unfortunately, neither Prinsley, nor the other physician geriatricians working in Victoria at the time – D.H. Blake and Boyne Russell – were in any position to made much of this opportunity. All of them were outsiders in the parochial Melbourne medical world: Russell because she was female, and only recently returned to Melbourne after an absence of some years; and the other two because they were newcomers to the city. Overall, not one of these physicians was in a position to pursue the cause of geriatric medicine through the arcane ways of the close-knit Melbourne medical fraternity, the interest-riven world of hospital administration, and the rigid division between the treatment of mental disease and physical disease. John Shepherd’s hope that Professor W.F. Anderson would take on the position that was eventually accepted by Derek Prinsley, was most likely based on the realistic assessment that only a strong personality with
11 VRRS 4523/2/381/7-105, letter to Manager of Mount Royal Hospital from CEO at St Vincent’s; Archives Geriatrics Society of Australia, letter dated 10/2/77 from R.B. Lefroy to Dr E. Wilder, Chairman Victorian Hospitals and Charities Commission in which Lefroy refers to plans made by the Queen Victoria Hospital with regard to geriatric medicine. 12 Annual Report St Vincent’s Hospital 1976. Mrs Marion Shaw reports a conversation with one of the Sisters of Charity, the Order that ran the hospital, in which the sister administrator expressed puzzlement at why the rehabilitation unit had been funded when they had requested permission to build a new pathology unit, Personal Communication from Mrs. Shaw, 11/11/97.
294 a well-established reputation in the field of geriatric medicine could hope to make any impact on these formidable obstacles.13
In the absence of any independent action on the part of Victorian geriatricians to organise and actively promote their role, it was the administrative purposes of the Hospitals and Charities Commission that prevailed in determining the scope of activity for the physician geriatrician in Victoria. The Commission’s objectives were supported by the interpretation, at the national level, of geriatric medicine as a subsidiary activity of medical rehabilitation, in association with community-based welfare services. David Race, Chief Clinical Officer in the Commission, made the extent of the geriatrician’s role clear in his address to community groups in 1974, and the positions available to the newly qualified physician geriatricians confirmed this orientation. Two of them took on the task of establishing the long-planned new centres in outlying suburbs, centres situated well away from the teaching hospitals, and the other two took positions in existing services at Mount Royal and Caulfield Rehabilitation Hospital.14
Although the physician geriatricians who qualified early in the 1980s were officially recognised within the profession and by the government bodies concerned with regulating the remuneration of specialists, they were almost as isolated as their general practitioner predecessors in the 1960s. Their workplaces separated them from their physician colleagues, and the lack of interest, if not outright animosity, evinced by general practitioners towards the role of geriatrician, did not diminish. Evidence for this may be found in the frequent and defensive, affirmations on the part of the
13 Letter dated 18/9/75, to Dr John Shepherd from Professor David Penington. It appears that Penington, going to England on other business, had agreed to seek out possible candidates for the position of Director of the institute proposed for Mount Royal and to interview doctors who had applied when the position was readvertised. It seems that Shepherd had suggested that Penington talk to Anderson who Shepherd thought might be interested in taking on this task. Anderson’s response was that he was not really interested but if Mount Royal were ‘in a hole’ in two years time he would reconsider the matter. Personal Papers Dr John Shepherd. Anderson himself accounted for his success in establishing geriatric medicine in Scotland and overcoming entrenched prejudice against doctors who worked with infirm old people as second-rate practitioners, only because of his ‘outstanding record, with so many fellowships and prizes that he could not easily be dismissed’, Thane, 2000, op. cit. p.451-452. 14 Dr Len Gray at Bundoora, serving the northern suburbs, and Dr R. Scholes, at what came to be known as the Peter James Centre, in the eastern suburbs. Both centres had been under consideration since the early 1970s. Dr Peter Lucas went to Caulfield Rehabilitation Hospital and Dr J. Tulloch remained at Mount Royal.
295 advocates of geriatric medicine of the importance of the role of the GP in providing medical care for the elderly.15 This animosity was not diminished by the steps taken in the mid 1980s, by the Federal government, to introduce a system whereby all applicants for nursing home admission were to undergo a process of assessment under the supervision of a geriatrician.16 Furthermore, where the first general practitioner geriatricians had the support of the medical administrators in the Hospitals and Charities Commission, this support disappeared in the reorganisation of the health services bureaucracy in the late 1970s when recommendations of the Syme-Townsend Report were implemented. The Hospitals and Charities Commission was amalgamated into a larger body, the Victorian Health Commission, along with the Department of Health and the Mental Health Authority and the Commission of Public Health.
At the suggestion of Marion Shaw, executive officer in the Geriatrics Division of the Hospitals and Charities Commission, this division was combined with the extra-mural psycho-geriatric services provided by the Mental Health Authority, and the welfare services provided by the Department of Health, to form an Extended Care Division.17 The new era was reflected in the naming of the ‘geriatric service’ established by Len Gray, one of the newly qualified physician geriatricians, in outer-suburban Bundoora – Bundoora Extended Care. The use of the term ‘extended care’ was, in part, the consequence of a movement that got underway in the
15 Sax, 1965, op. cit. p.26; Lefroy, 1966, op. cit. p.206; A.M.A. (Victorian Branch) Monthy Paper, no 110, 1972, p.4; ‘Geriatrics’ editorial, MJA, vol 1, 1975, p.87. In 1987 R.W. Warne, a physician in geriatric medicine at Mount Royal, was taken to task by a general practitioner for failing to mention the importance of the part played by the GP in providing medical services to elderly people, in an article describing the development of geriatric medicine, R.W. Warne, ‘Issues in the Development of Geriatric Medicine in Britain and Australia’, MJA, vol 146, 1987, pp.139-141; ‘Geriatric Medicine’, letter from I.G. Chenoweth, MJA, vol 146, 1987, p.400. 16 In Chapter Five it was noted that in the early 1970s, in an effort to exert some control over admissions to nursing home care, and thus over a growing financial responsibility, the Federal government introduced a system whereby an official form had to be filled out by the doctor supervising admission, and verified by a medical officer attached to the Commonwealth Department of Health. A decision to admit was rarely, if ever, contested. In the two reports on ‘care of the aged’ that issued from the Federal government in the mid- 1970s, assessment was recommended both as a means of curtailing costs and ensuring that dependent old people were assisted in a manner that maximised their independence, not their dependence. For assessment to be effective it was necessary to establish a degree of local coordination in the provision of services and a range of services. These were included amongst the recommendations that were finally implemented by the Federal government following yet another report, In a Home or at Home, Report from the House of Representatives Standing Committee on Expenditure, (Sub Committee Chairman L. McLeay) 1982, Australian Government Publishing Service, Chapter 8. 17 Personal communication from Mrs Marion Shaw, March, 1997.
296 mid-1970s, to promote the needs of disabled people who could benefit from the services provided in the geriatric centres but who were excluded on the grounds of age, and in part an attempt to minimise the connotation of permanence associated with the expression ‘long-term’ in reference to the care provided for the infirm aged and disabled.18
In 1980 a medical practitioner was appointed in charge of this Division. Strangely, in view of the expertise that had accumulated amongst Victorian geriatricians over the preceding years, it was not one of these practitioners but a surgeon who had developed an interest in rehabilitation.19 It is not clear whether this situation arose from the ignorance of policy makers and their advisers of the expertise that was available, or whether they chose to ignore it. It may also have been the case that the stance of Victorian geriatricians, who on the whole appear to have shown no interest taking on administrative responsibilities of this kind, did not encourage overtures. The result was that the general trend in Victoria to define the role of the physician geriatrician in relation to services located outside the acute hospital was reinforced. Any other possibility that may have lingered around the Hospitals and Charities Commission disappeared in this new administrative entity, and geriatricians themselves had no say in matters relating to the conditions in which they worked.
The only sign of recognition accorded to Victoria’s physician geriatricians was the presence of Boyne Russell in the Working Party on Extended Care of the Aged and Disabled that was established at this time. Possibly it was
18 Minutes Meeting Medical Superintendents, Managers and Officers of Hospitals and Charities Commission, 12/3/75, note that the Geriatric Hospitals now need to formulate new policy in the light of legislation to ensure that younger adults suffering from chronic illness and disability could not be excluded from institutions on grounds of age, see Scotton & Ferber, 1978, op. cit. p.221. 19 Dr A.R. Moore, FRACS, combined his position in the Health Commission with an appointment as staff specialist at the Rehabilitation Hospital at Hampton where he was appointed Medical Director in 1985. Moore had previously worked as surgeon at the Royal Melbourne Hospital. His contact with geriatric medicine came with an appointment as surgeon for Mount Royal Hospital where he would have seen what was done in the provision of geriatric services. Like Bruce Ford, Director of Rehabilitation Services at Caulfield Hospital, Moore also had a ‘humanist’ qualification. Where Ford’s was in the field of sociology, Moore gained a Master of Arts degree. As Senior Lecturer in Surgery in the medical school at the University of Melbourne Moore introduced a short course that called ‘Medical Humanities’, using excepts from literature related to medical practice, to encourage students to consider medicine as an art, not just a science. The texts and some excerpts form the discussions in this seminar are reproduced in, A.R. Moore, The Missing Medical Text, Humane Patient Care, Melbourne University Press, Melbourne, 1978.
297 her influence that led to the inclusion of a note to the effect that development in the provision of extended care depended on changes in the provision of acute medical care for this group.20 The effect of this statement was somewhat diminished by comments to the effect that there was no expectation that the Health Commission would sponsor the development of geriatric medicine. It was indeed a sign of change that the inadequacy of acute care for some elderly people was noted in an official document in Victoria. Previously this point had been confined to the study published by G.V. Davies in the early 1960s, and Boyne Russell’s report on the Brunswick Community Care Program ten years or so later. There was, however, no intention in the state’s health bureaucracy of acknowledging such a need in the organisation of acute hospital services.
In contrast to the nascent orthopaedists in England, studied by Roger Cooter, who acted as specialists before they could demonstrate the trappings of specialist status, these first physician geriatricians in Victoria were designated specialists before they were in a position to act as such. They did not so much define their specialist role as have it bestowed upon them as part of the process in which a charity model of care for the aged and infirm was transformed into a service model based upon professional assessment of need. This transformation was part of a growing bureaucratisation of the provision of publicly funded hospital and welfare services, as both state and federal governments sought to control increasing expenditure. The provision of geriatric services, available to all citizens as a matter of entitlement, with the associated requirement for efficient management, sat uneasily with the humanitarian recognition of the neglect that saw infirm old people confined to institutional care as a matter of course.
No sooner had the first steps been taken in establishing geriatric services in Victoria as a setting for the specialist physician geriatrician, than the effects of the economic downturn that distinguished the 1970s from the more prosperous 1950s and 1960s were felt. Speaking from the vantage point of 1984, Sidney Sax noted that from the end of the 1970s, ‘planning and expansion of organised geriatric services gradually gave way to hard-
20 VPRS 4523/P2/524/8670. Discussion document related to the report of the Working Party on Extended Care of Aged or Disabled Persons, June, 1981.
298 fought struggles to hold ground already won’.21 The situation was further complicated by the replacement of the centralising and innovative Whitlam government at the federal arena by a conservative regime under a Liberal-Country Party Coalition which at once set about pursuing a decentralising agenda. As responsibility for hospital and welfare services shifted back to the states, the existing tendency in Victoria toward fragmentation of services was reinforced. In addition, the support provided by the Hospitals and Health Services Commission for socio- medical hospital services diminished. The shift towards conservatism in the federal arena favoured the conservative element in the medical profession which, in Victoria, had shown little interest in the provision of rehabilitation services.22
Defining the geriatrician’s work How was the role of geriatrician to be defined in these circumstances? David Armstrong has noted that in defining geriatrics in relation to old age, geriatricians faced the problem of differentiating between age-related changes and those attributed to disease when the same classificatory device – changes in tissues and cells – was used to describe both forms of change.23 It has been suggested in this thesis, a suggestion inspired by Armstrong’s discussion of geriatric medicine in a later work, that the structure of the geriatric service and emphasis on clinical experience and judgement in the role of the physician geriatrician provided a practical response to this problem.24 In Victoria, if physician geriatricians had themselves played a stronger role in establishing the conditions that made
21 S. Sax, ‘Perspectives on the Development of Gerontology in Australia’, Proceedings 20th Annual Conference, Australian Association of Gerontology, 1985, p.8. Geriatricians, situated as they are on the boundary between acute medical services and services related to care of the aged, are particularly susceptible to fluctuations in funding and shifts in responsibility between the states and the Commonwealth. Once again in the early 1990s geriatric services were curtailed as efforts were made to restrict public funding of hospital services at the state level while there were minimal constraints on the federal funding of fee-for-service medicine through the national health insurance scheme, L. Flicker & L. Gray, ‘Issues in Geriatric Medicine’, Australian Journal on Ageing, vol 16, no 3, 1997, p.107-108. 22 The National Hospitals and Health Services Commission was abolished following the replacement of the Whitlam government by the Fraser government at the end of 1975. However a Social Welfare and Health Policy Secretariat was established with Sidney Sax as head, to be responsible for development and review of federal policy, Scotton & Ferber, op. cit. p.332. Following the review instigated early in 1976, of the various bodies that had been conducting inquiries, the Working Party on Rehabilitation Needs and Geriatrics was terminated immediately. 23 D. Armstrong, ‘Pathological Life and Death: Medical Spatialisation and Geriatrics’, Social Science and Medicine, vol 15A, 1981, p.254-255. 24 Armstrong, 1983, op. cit. p.91-92.
299 their specialty possible, a definition such as Boyne Russell’s, in terms of context or chronological age, may have prevailed.25 As it was, Victorian geriatricians were relieved of the problem of defining their medical role in relation to old age infirmity because the Hospitals and Charities Commission, the dominant party in establishing geriatric medicine in Victoria, made an administrative decision to locate geriatric services outside the field of acute hospital practice. The problem that faced Victorian geriatricians, and indeed geriatricians and medical rehabilitationists throughout the Australian medical system, was to integrate their socio-medical model of practice with the existing disease- based model.
The location of geriatric services within the field of ‘aged care’ certainly reflected an overall lack of interest in old age infirmity on the part of mainstream medicine, and geriatricians’ lack of influence in the organisation of hospital services in Victoria. However, it also reflected an underlying orientation to medical practice characteristic of medicine in Australia, an orientation that may be illustrated by comparing David Race’s notion of social medicine with that of Eric Saint. When Saint discussed social medicine, he did so by calling for a shift in clinical philosophy so that all doctors would be equipped to think in terms ‘not only of signs and symptoms, but also of population statistics, of housing, of hospital administrative problems, of dietetics and of the rudiments of psychiatry’.26 David Race, on the other hand, made it clear that geriatric medicine exemplified a social medicine consisting in a range of welfare measures made necessary by the undeveloped status of medical science in relation to some aspects of old age degeneration.27 This formulation does not contest the fundamental philosophy underlying medical practice in the way Saint’s does. On the contrary, it reaffirms this philosophy and in doing so is consistent with the ‘medical materialism’ that Gillespie discerned in the Australian medical profession, whereby economic, social and political phenomena were seen as manifestations of more fundamental medical causes.28
25 B. Russell, 1977, op. cit. p.111; see Chapter Six. 26 Saint, et al, 1953, op. cit. p.764. 27 See Chapter Six. 28 See Chapter Two.
300 From the perspective of social medicine in the Victorian context, the provision of geriatric services, and the role of the geriatrician, was a practical response to a situation in which an ‘ageless’ medical science had yet to come to grips with certain problems. It was, therefore, consistent with the overall medical framework characteristic of the Australian medical profession, that the geriatrician’s role would be defined in relation to the provision of certain welfare services. In developing their role within these parameters, geriatricians were free to draw on a growing body of gerontological knowledge in the disciplines of biology, sociology and psychology, and indeed to cultivate such knowledge themselves to the extent that they could procure the funding to do so. As it was, in the 1980s the place they were offered within the overall organisation of medical practice, through the funding measures provided by both State and Federal governments, meant defining the geriatrician’s role fundamentally in terms of service provision. This is reflected in geriatricians’ own definition of their role as: … an appropriately trained specialist (FRACP or equivalent) working within a multidisciplinary team of health professionals providing health care in terms of medical, functional and social needs for elderly clients on an area (regional) basis.29
However, in fitting so readily into the framework of service provision, geriatricians faced the problem that health services are not always rationally allocated and that political skills and leadership are necessary to bolster the development of the specialty. It is worth noting that physician geriatricians found a somewhat more sympathetic environment, at least in terms of an administrative environment, in the hospitals run by the Commonwealth Repatriation Department for returned service personnel.30 The justification of the role of geriatrician in terms of population health and the rational organisation of medical services did not amount to much in the interest-ridden environment of Victorian health services and the competitive environment in which research funding was distributed. The conditions that made it possible for doctors to establish a specialist medical role in relation to old age infirmity in Victoria were notable for
29 Lefroy, 1988, op. cit. p.69-70. 30 See Sax 1965, op. cit. for New South Wales; see Hunter-Payne, 1994, op. cit. for geriatric medicine in the Victorian Repatriation Hospital, p.164ff.
301 the absence of any energetic and strong leadership. This created an environment in which geriatricians, in contrast to their more entrepreneurial colleagues, tended to adopt a somewhat passive stance in promoting their expertise, an expertise that was implicitly acknowledged in the public discussions on the topic of the ‘problem of old age’.31 However, in relying on the inherent logic of arguments about the needs of a growing population of elderly people and rational assessments of hospital provision, they failed to hone the political skills necessary to establish their interests amongst all the others that were embedded in the provision of hospital services. These specialists, situated on the boundary between hospital services and welfare, were then at the mercy of every shift in the political wind. In the 1980s after a Victorian branch of the Australian Geriatrics Society was formed, ten years after the Society was established, the interim committee was preoccupied with a manpower study. Meanwhile, other academic and hospital interests were busy at work establishing Chairs of Geriatric Medicine and disestablishing them as though they had nothing to do with the specialty of geriatric medicine and indeed the relationship was tenuous.32 The promotion of ‘geriatrics’ – care of the aged – did not necessarily mean promotion of a specialist field of medical practice.
The emergence of geriatric medicine as a specialist field of practice made workable a system of medical care based on individualised, technical services developed within a reductionist model of disease. The development of a field of medical rehabilitation, which included geriatric medicine, meant that the narrow focus on curative measures in the acute hospitals was not contested. The lack of public appreciation for the role of the geriatrician suggests that the emphasis on curative measures in the provision of health services was supported in the Victorian community.
31 For example, in the two inquiries conducted into ‘care of the aged’ in the mid-1970s, at the instigation of the Federal government, the role of the geriatrician was acknowledged, but only in circumstances where recommendations relating to policy could be made, not implemented. 32 Minutes Meeting Interim Committee, Victorian Branch, Australian Geriatrics Society, March 1984; Minutes Meeting Committee (Mount Royal) National Research Institute for Gerontology and Geriatric Medicine, 6/12/84, notes a committee set up by University of Melbourne to review the Chair in Geriatric Medicine and to make an appointment following the retirement of Professor Prinsley at the end of 1986. As it happened the position was reduced to associate professor level. At Monash University a Chair of Geriatric Medicine was established in the early 1980s.
302 The second point in relation to the emergence of geriatric medicine and the overall process of specialisation is that it testifies to the pervasiveness of specialisation. It was possible that the system in Victoria - whereby the Diploma in Geriatric Medicine provided a postgraduate qualification for general practitioners who were then recognised as specialists by the Hospitals and Charities Commission and paid accordingly - would prove satisfactory at the local level. General practitioners interested in this work would have found it worthwhile to develop their interest and the state-run geriatric centres would have had a source of medical staff. If the links between the Victorian Faculty of the Royal Australian College of General Practitioners and, for example, the local Association of Geriatric Medical Officers had been developed further, it might have been possible to integrate the practice of geriatric medicine into general practice.
There were certainly local obstacles to this development. The reluctance of the Association to develop a professional identity in place of the parochial and narrow institutional orientation of many local geriatricians tended to isolate geriatricians from their fellow general practitioners. This was reinforced by the aversion amongst general practitioners to any close association with state institutions like the geriatric centres, and to the idea of practising medicine in tandem with other health professionals such as nurses therapists and social workers. However, local arrangements became less sustainable from the 1960s on, in an overall shift to a national organisation of medical services in relation to accreditation and training and remuneration for medical services. Local general-practitioner geriatricians were effectively, if not intentionally, sidelined in the general move on the part of the physician members of the Australian Geriatrics Society to have special training in geriatric medicine accepted by the Royal Australasian College of Physicians. The desire of these physicians to integrate geriatric medicine with medical practice at consultant level reflected the reality that doctors at this level dominated medical education and training. If the principles of geriatric medicine were to be introduced into the work of all medical practitioners, its practitioners had to operate at the highest level of qualification.
Geriatric medicine was a late-comer to the proliferation of specialties that began in the 1960s. The overall trend towards specialisation was
303 reinforced when differential rates of remuneration were introduced into the national system of hospital and medical insurance in the early 1970s and the National Specialist Qualification Advisory Committee was established. In these circumstances the general practitioner geriatrician in Victoria, the geriatric medicine officer trained through the Diploma program, gradually faded from view.
The third, and final point is that the development of geriatric medicine in the form of service provision also reflected a process of specialisation in which the Australian medical profession was able to maintain its entrepreneurial character, while at the same time entering into a closer relationship with government in the provision of health services. This association - which had existed since the early 1950s in the federal arena, when the British Medical Association had dictated the terms for a national system of hospital and medical insurance – was obscured in the arrangement whereby governments, both state and federal, provided subsidies for medical services rather than the services themselves. Even with the introduction of universal, publicly funded insurance, the insistence on the part of the medical profession on retaining fee-for- service remuneration for medical services, ensured the status of geriatric medicine would remain low. In comparison with other medical specialties, the service provided by the geriatrician was time consuming and, ideally, required the services of the social worker, nurse and occupational or physio-therapist. The possibilities for earning the same level of income as their colleagues in the other medical specialties were not there. In the early 1980s, an oversupply of physicians in the field of gastroenterology did not encourage doctors to shift into the under-supplied area of geriatric medicine.33
33 Newsletter, Australian Geriatrics Society, October, 1989, notes difficulty in recruiting registrars to do their physician training in geriatric medicine, only half the number needed was available.
304 Geriatric Medicine and the Public Understanding of Old Age If the role of specialist physician geriatrician made an increasingly specialised and expensive system of medical services workable, what significance was there in the emergence of this role for the public understanding of old age? The first steps to promote a special medical role in relation to old age were taken alongside a general community movement in which voluntary groups and professionals began to view old people in Victoria from perspectives formed largely in the United States and Britain, and publicised in the literature that proliferated on the ‘problem of old age’ from the 1940s onwards. The first attempt to formulate the local version of this problem can be found in the survey undertaken by Bertram Hutchinson, a social investigator brought from England by the Rotary Club of Melbourne. The advocates of geriatric medicine in Victoria, were prominent in the field of activity that began to take shape at this time around the needs of old people. The emphasis geriatricians placed on the representation of old age as a period of activity supported the objectives of groups like the Old People’s Welfare Council as it took on the task of raising the status of the aged. It also supported the voluntary groups in shifting their work from a basic provision of custodial care to a professionalised activity providing age-specific services.
On the level of what was actually done and the formation of policy, medical influence was not great, particularly in Victoria. In relation to policy at both state and federal levels, the valid point that the needs of some acutely ill old people were not met within the existing organisation of hospital and medical services, was lost amidst the profusion of interests and generalised formulations of the ‘problem of the aged’. The advocates of geriatric medicine were caught in a bind because on one hand they, like all medical specialists, needed the support of lay groups in making their claim to specialist expertise. However, their interests were not always advanced through this association. The point they made in relation to hospital services, was lost amidst a maze of other matters in the field classified as ‘care of the aged’. There was certainly a relationship between the acute hospital services they advocated and community-based welfare services but this was obscured in discussions dominated by ‘the problem of old age’. Their task was made more complicated than that of other medical specialists because the field they worked in straddled the unstable
305 ground of state/federal funding. A gain secured in one arena could be undone by actions taken in the other, a situation exemplified by the introduction of subsidies for nursing home care by the federal government.
Even when, in the 1960s and 1970s, there was greater acceptance of the idea of providing community-based services instead of institutional care for the chronically ill and disabled, geriatricians were at a disadvantage. On one hand they were in step with this movement in seeking to shift the emphasis away from the provision of institutional care for the infirm aged. On the other hand, however, they were out of step because in this process there was also a tendency to contest medical control. The distinction between the role of the geriatrician in assessment and rehabilitation, and that of the Health Department medical officer’s determination of access to domiciliary services was one not everyone was able to appreciate. In the 1980s, when geriatric medicine was funded by measures designed to provide hospital-based rehabilitation treatment, geriatricians were at a disadvantage in access to private patients. Their better-organised colleagues in medical rehabilitation had secured an arrangement with the health insurance funds so that claims could be made for rehabilitation treatment only when it was provided in a hospital under the direction of a member of the Australian College of Rehabilitation Medicine.34
David Armstrong has brought a Foucauldian perspective to bear upon the emergence of social medicine in Britain in the period between the wars and just following the Second World War. Geriatric medicine with its socio-medical model of illness in elderly people is included in this process, which entailed a shift in the medical ‘gaze’ from the narrowly defined space of the hospital ward into the broader social space of the community.35 The ‘geriatric patient’ was identified by means of the social survey, a tool that brought a previously undifferentiated mass of old age-ill health and disability to light, in the form of changes in the ‘morbidity spectrum’ from acute to chronic illness.36 The geriatric service provided
34 Australian Geriatrics Society, Federal Council Meetings, Minutes/Agendas, February, 1990, notes that the issue of accreditation of the geriatric centres in Victoria for the purpose of claims on hospital insurance, was still unresolved. One of the largest health insurance funds, Medibank Private took recommendations only from the Australian College of Rehabilitation Medicine. 35 Armstrong, 1983, op. cit. p3-4. 36 Ibid. pp.85-87.
306 an organisational form for the panoptical surveillance of this patient as he or she moved along the trajectory of decline to death. Armstrong cites Sheldon’s survey of elderly people in the city of Wolverhampton as the earliest example of ‘a technology through which power operated as a positive force, making it possible to constitute and sustain ‘the very conception of ‘natural history’ as applied to illness’.37
Moira Martin has criticised Armstrong’s interpretation of the disciplinary potential of geriatric medicine in England in the 1950s on the grounds that the most that was achieved was an improvement in the system of classifying elderly people and ‘distributing them to the most appropriate site in a network of care established by postwar reforms’.38 If the disciplinary power of geriatric medicine in England was somewhat uncertain in the 1950s, in Victoria there can be no doubt that even into the 1980s the ‘geriatric patient’ was a most unstable and indefinite category. On the whole, medical practitioners in Victoria had little interest in shifting the medical ‘gaze’ away from the hospital into the community. General practitioners, for their part, were reluctant to relinquish their entrepreneurial status and to act openly as accomplices with the state in establishing a corporate society. The stance taken by mainstream medicine was reinforced by the persistence of community participation in the provision of health and welfare services, either in the form of voluntary societies or private business. The slow replacement of the charity model whereby volunteers and an untrained workforce cared for the infirm aged, by a professionalised workforce and administration did not minimise the importance of community ideas about the appropriate response to old age infirmity. If the geriatric patient could be said to be the product of disciplinary power at all in this period, it was the administrative discipline that was first introduced, tentatively, with the establishment of the Hospitals and Charities Commission and, later, the Victorian Health Commission. Even into the 1980s, this form of ‘discipline’ was limited in its power in relation to community groups
37 Armstrong, 1983, op. cit. p.86. 38 Martin, 1995, op. cit. p458.
307 although local administrative discipline was reinforced by the moves made by the Commonwealth to establish the geriatrician as gatekeeper to publicly subsidised nursing home care.
Notwithstanding Martin’s critique of Armstrong’s interpretation, and the very uncertain development of geriatric medicine in Victoria, the central point of Armstrong’s analysis remains undiminished.39 That is, the emergence of the ‘aged subject’ marked a new cognitive and political domain. The obstacles Martin identifies to the development of geriatric medicine as a disciplinary power suggest that the emergence of such power in liberal democracies may be more complex than appears from an analysis of texts. Martin’s interpretation may be read as amplifying Armstrong’s analysis, giving it more depth, if less clarity, by highlighting the competitive character of the process through which the postwar ‘elderly citizen’ was constructed. A focus on the slow development of geriatric medicine in Victoria may obscure the point that when the role of geriatrician was introduced, even in the late 1950s, old age was already the object of disciplinary power - but power more aligned to the requirements of government than to specialist fields of expertise.
Nicholas Brown’s insights into the operation of disciplinary power in the 1950s offer a way of interpreting an environment that was clearly more unstable than Armstrong’s analysis allows for, while at the same time making it clear that, around this time, a new cognitive and political domain around old age was emerging. Brown describes a disciplinary environment where a range of diverse groups, accustomed since wartime to playing a role in public discussion and the formation of public policy, sought to work out a way to come to terms with the changes brought about by postwar affluence. These changes were seen in a growing materialism, mobility and social fragmentation in Australian society.40 It was indicative of the environment in which government operated at the time that the participants included those involved in a changing model of industrial relations, lobbyists for sectional interests, and others from financial journalism and the discipline of economics. The concept of the ‘citizen as consumer’ emerged out of the varied and not easily reconcilable
39 Martin, 1995, op. cit. p.443. 40 Brown, 1995, op. cit. p.4.
308 standpoints that were represented in social analysis at the time. It was a process where an accommodation was reached between the discursive field of managing the needs of the population, and that of maintaining the requirements for stable government.41
In linking the emergence of a discursive field with the requirements for stable government, Brown’s interpretation offers a way of aligning Martin’s conclusion that geriatric medicine in Britain in the 1950s did not construct its object because it was too fragmented and uncertain a field, with Armstrong’s insight that as ‘a medicine of the social was born’ in interwar Britain, so did ‘a politics of the social become a possibility’. The failure of both psychiatrists and geriatricians in Victoria to achieve anything substantial in the form of disciplinary development prior to the early 1980s should not obscure the point that, during the 1950s and 1960s, a more diffuse discursive field related to old age did exist within the broader concern to govern the citizen as consumer. This individual was ‘located in a more socially inclusive private sphere of desires and aspirations’ which required regulation to prevent inordinate expenditure on one hand, and oppressive taxation on the other. The citizen consumer was described in the discourses of economics, industrial relations, psychology, finance and business.42
The aged citizen consumers could be found in the subculture described by the psychiatrist Herbert Bower in 1964. It consisted of a rapidly expanding group of old people with: … fair financial power, ample free time and reasonable health [who] could [be] expected to develop into a political pressure group [but] does nothing of the kind. The old show no hunger for power, have little solidarity and disengage themselves in a curiously passive way from life around them.43
Dewedney and Collings found the working-class equivalent when they surveyed the elderly residents of inner-city Richmond. To the puzzlement of their middle-class interlocuters, these people were content to live quietly amongst familiar surroundings without doing anything much in
41 Ibid. p.4-5. 42 Ibid. p.102. 43 Bower, 1964, op. cit. p.286-287.
309 particular, and resenting any endeavours on the part of professionals to ‘correct their apparent boredom’.44 The psychologist Ronald Conway, in the early 1970s, linked the ‘tragic uselessness and spiritual sterility’ of so many retired people to the psychologically barren utilitarianism that informed the Australian philosophy of life.45
It could also be said that these complacent old people were exemplars of the citizen consumer in the careful cultivation of their private lives. They avoided the careless spending characteristic of securely employed workers, and in home-ownership and a carefully regulated personal life they did not threaten the collective well-being by calling upon public assistance. The Age Pension was simply what they were entitled to after a life-time of hard work.46 It was the poor aged who depended on the pension for their whole income and who did not own their home, who were the focus of the Keynesian economics which was the prominent discourse in public life in Australian in the 1950s. Richard Downing, Ritchie Professor of Economics at the University of Melbourne, paid particular attention to the integration of the elderly (defined in relation to age of eligibility for the Age Pension) into consumer society. He presented a five-point program for this in the early 1950s in which the level of pension payments was adapted to the needs of beneficiaries. In doing so he worked from the principle that there was ‘a given standard of entitlement accruing to each citizen, to be realised in an environment offering an assessment of need and an ethic of redistribution’.47
The first challenge to the prevailing economics discourse was made by Bertram Hutchinson when he called for a remaking of a ‘social norm’ of old age.48 Although Hutchinson was responding to the comments made by the old people he surveyed, which conveyed feelings of alienation and exclusion, when elderly people did organise to protect their interests it was not their status that they were concerned about. Rather, it was the desire
44 M. Dewdney & J.S. Collings, Living on the Old Age Pension, Hospitals and Charities Commission, Melbourne, 1965, p.113. 45 R. Conway, The Great Australian Stupor, An Interpretation of the Australian Way of Life, Sun Books, Melbourne, Australia, p.183. 46 The economist Douglas Copeland coined the expression ‘milk bar economy’ to convey the threat he perceived in an unbridled consumerism, to the overall well-being of the nation, Brown, 1995. op. cit. pp.109-111. 47 Brown, 2001, op. cit. p.185ff. 48 Hutchinson, op. cit. p.4
310 to protect the benefits due to them in the form of the Age Pension that brought them together.49 For those other elderly people who sought to advance the status of the aged by forming the Old People’s Welfare Council of Victoria, some of whom were associated with the Rotary Club of Melbourne which commissioned Hutchinson to undertake the survey, the project seems to have been yet another version of charity work albeit with a gloss of professionalism.50 It is unlikely that the retired businessmen and society women who took up the problem of aged as part of a lifetime of voluntary work for the less fortunate, ever considered that they needed the Elderly Citizens Clubs they encouraged the Department of Health to fund.51 The warm reception received by the founders of the Old People’s Welfare Council, first at the state level and then in the federal arena, arose out of a shared set of social values, the same ones that underpinned the citizen as consumer. In view of the ages of federal and state parliamentarians at the time, shared generational values also played a part.52
49 I. Ellis, ‘Pensioner Organizations and Action’, in Towards and Older Australia, Readings in Social Gerontology, ed A.L. Howe, University of Queensland Press, St Lucia, 1981; Gilsenan, 1999, op. cit. 50 Norris, 1978, op. cit.pp.95-98. The Victorian Council proposed that leadership courses be introduced for the secretaries and leaders of the Elderly Citizens’ Clubs, Newsletter, National Old People’s Welfare Council of Australia, February, 1961. 51 The Lord Mayor of Melbourne, Councillor Disney, hosted the inaugural meeting of the Victorian Old People’s Welfare Council, at the Town Hall. Mrs Herbert Brookes, daughter of Alfred Deakin, and Mrs F.G. Tuddenham exemplified the socially prominent women who, as members of the National Council of Women, Victoria, devoted their undoubted capacities for leadership and organisation to addressing a range of social problems. ‘Old age’ was only one of a number of issues the Council took up, others being mental illness, education, the welfare of children and mothers and the rights of women to participate in civil society, Norris, op. cit. Sir Giles Chippendall, first president of the National Old People’s Welfare Council exemplified the businessmen and public servants who maintained an active life after retirement, devoting themselves to the ‘problem of old age’, Newsletters National Old People’s Welfare Council of Australia, Archives, Council for Ageing, Victoria, Box 1. Chippendall entered the Commonwealth Public Service as a messenger boy and left it having reached the position of Director-General of the Postmaster General’s Department. He is described as a ‘tough-minded administrator who got things done’, Australian Dictionary of Biography, vol 13: 1940-1980. 52 Holmes, 1976, op. cit. p.17; G. Henderson, Menzies’ Child, The Liberal Party of Australia, 1955-1994, Allen & Unwin, St Leonards, NSW, Australia, 1994, p179. The Victorian Minister of Health agreed that his Department would provide funding to assist councils in establishing Elderly Citizens’ Clubs. When a National Council was formed by existing state Old People’s Welfare Councils, the Prime Minister, Sir Robert Menzies agreed to provide a most generous thirty thousand pounds annually for three years to assist the Council in its work. By the end of the 1960s the names of federal and state bodies had been changed to Australian Council on the Ageing and Victorian Council on the Ageing respectively. VPRS 105546, Victorian Council on the Ageing
311 The emerging activism of ‘the aged’ in the 1950s, if such a positive term can be used in relation to the restrained activities of the Old People’s Welfare Council and the various pensioner associations, was directed towards ensuring that the elderly were maintained within that ‘socially inclusive private sphere of desires and aspirations’ through a range of age- specific welfare measures.53 To the extent that this entailed a redefinition of the ‘norm’ of old age in general and not simply ‘poor old age’, it was a redefinition not of what it meant to be old but of what it meant to be an old consumer. The various age-specific subsidies that were made available during the 1950s and 1960s, for housing, medical services, and long-term care, were subsidies for private choice. They may be seen as part of a process which Thane and Harper have defined as the ‘social construction of old age’, a process whereby elderly people come to be defined and categorised, and have characteristics attributed to them, which then become normative’.54 When the psychiatrists Davies, Bower and Stoller called for the psychological and sociological studies to build up a body of knowledge to support older adults in the project of ageing ‘successfully’, they were not so much voices ahead of their time, as representative of an existing trend whereby problems of social order were approached through the cultivation of personality.55 Their objective was to include ageing adults in this process: an objective that was it appears, of little interest to professionals at the time, including psychiatrists, in the overall concern with adolescents, families and migrants.
Throughout the 1950s and 1960s, as the conditions emerged in which geriatric medicine became a specialist field of medical practice, the social construction of old age proceeded to the extent that a historian of the 1970s included ‘the aged’ as a specific social grouping.56 The medical profession played its part as advances in technique meant that the degenerative diseases associated with old age became more amenable to treatment. Nascent geriatricians also contributed as they sought to establish the provision of rehabilitation treatment as a routine measure for old people at risk of needing custodial care. Their success in this project
53 Brown, 1995, op. cit. p.102. 54 Harper & Thane, 1995, op. cit. p.44. 55 Brown, 1995, op. cit. p.168ff. 56 F. Crowley, Tough Times, Australia in the Seventies, William Heinemann, Australia, 1986, p.248.
312 was uneven, but there can be no doubt that this emphasis on activity in maintaining good health in old age contributed to the overall process in which old age was brought into the discursive field of good governance that was established in the postwar period. It is not accidental that the body of knowledge that defined geriatric medicine in the early 1980s was principally defined in terms of the provision of services rather than, for instance, the diseases of old age, and that the ‘aged subject’ was found mainly in government reports.57 Armstrong’s claim that as ‘a medicine of the social was born’, so did ‘a politics of the social become a possibility’ can be sustained in relation to the emergence of geriatric medicine in Victoria only by taking note of the particular circumstances in which this process got underway. A medicine of the social which consists principally of the provision of services designed to maintain the infirm aged as participants in their communities, reflected the requirements for integrating ‘the aged’ into consumer society as a means of making the most efficient use of public resources.
There can be no doubt that the introduction of the role of specialist geriatrician benefited a neglected segment of the Victorian population – that is those old people, most of them poor, who were consigned to custodial care without any consideration as to whether there could be any alternative to incarceration. In circumstances where the infirm aged were excluded from the acute hospital, it is understandable that the advocates of geriatric medicine should emphasise rehabilitation and integration with other hospital patients on one hand, and with community life on the other. It is notable however, that in emphasising the benefits of providing active medical treatment for a group that, in the course of the twentieth century had been excluded from this sphere, two points are obscured. The first is that many old people could not benefit from rehabilitation treatment. The exclusion of nursing home care from the field of hospital provision meant that unlike the private hospitals where acute medical treatment was provided according to enforceable standards, private nursing homes were
57 A.L. Howe, ‘Gerontology in Australia: The Development of the Discipline’, Educational Gerontology, 16, 1990, p.127-128; Report of the Committee on the Care of the Aged and the Infirm, Chairman, A.S. Holmes, January, 1977, Australian Government Publishing Service, Canberra; Report of the Australian Government Social Welfare Commission, Care of the Aged, Chairman, M. Coleman, Australian Government, Canberra, 1975.
313 outside the geriatrician’s jurisdiction unless individuals were able to establish the appropriate relationships with the private providers.
The second point that is obscured is that the natural end of old age lies in death. If death was an affront to medical knowledge in the acute hospitals, it seems also to have been out of place in the provision of geriatric services. Death was certainly included amongst the topics covered in the two gerontological texts that were published locally in the 1980s.58 However this recognition seems to have arisen more as a consequence of the emergence of the hospice movement as a means of attending to an existing neglect of the dying, than from any particular attention to the point that death follows old age.59 In addition many old people died in nursing homes, attended by staff whose training, if they had any at all, may not have equipped them with the skills available to hospice staff, and by general practitioners who may or may not have been interested in their plight.
In the community, the emphasis on activity on the part of the aged care experts (doctors, nurses, therapists and social workers), and on the part of activists in the cause of ‘old age’, left no space at all for referring to death as a natural event which is sometimes accompanied by intractable difficulties. The social construction of old age left out death with the consequence that those who could not benefit from rehabilitation – a category which may have included individuals who were making their own private accommodation with impending death - the unduly loquacious, the disoriented and the unmotivated - were left in limbo.60 Marjory Warren promoted the development of geriatric services as a more humane response to old age infirmity than ‘whispered’ arguments in favour of euthanasia, and to the extent that the introduction of geriatric services in Victoria provoked a more life-affirming response to old age
58 K. Kingsbury, ‘Some Last Choices’, in Towards an Older Australia, Readings in Social Gerontology, ed A.L. Howe, University of Queensland Press, St Lucia, 1981; R. Webster, ‘Palliative Care in the Elderly’, in R.W. Warne & D.M. Prinsley, eds, A Manual of Geriatric Care, Williams Wilkins and Associates Ltd, Sydney, 1988. 59 A distinction between adults dying from a disease such as cancer and the ‘aged and infirm’ who may also be near the end of life, was made on the grounds that ‘in the first place the age span is much wider and an substantial proportion of patients do not see themselves as belonging to the category of the ‘aged and infirm’’, and that ‘there is the certainty (with cancer patients) that, sooner or later, their malignant disease will kill them’, D. Allbrook, ‘Dying of Cancer, Home, Hospice or Hospital’, MJA, vol 143, 1984, p.143. 60 G. Larkins, ‘Physical and Mental Problems of Ageing’, in Stoller, 1960, op. cit. p.28.
314 infirmity, this was successful.61 However the emphasis on activity in public discourse left no room for a public view about preparing for death. Any faltering in the will to live or difficulty in adjusting is addressed in the form of additional services or a readjustment of medication. Possibly this is be all that can be expected from hospital and medical services. The problem is, however, that as old age has become medicalised to the extent that a medical response is considered by both the lay public and the profession to be appropriate in all cases of dis-ease, there are no other legitimate categories for talking about death at the end of a long life. Any contest to medical authority from the other professions that have developed a role in relation to old age – nursing and social work for example – did not necessarily contest the technical orientation of medicine but merely substituted another form of it. During the 1970s and 1980s, when the role of geriatrician was established in Victoria’s hospital and medical services, it was in novels that the most eloquent examination of the experience of dying in old age was to be found.62
61 Warren, 1946, op. cit. p. 842. 62 Hartshorn 1993, op. cit. lists Elizabeth Jolley’s Mr Scobie’s Riddle, Patrick White’s The Eye of the Storm, and Jessica Anderson’s Tirra Lirra by the River, as exploring questions related to old age and death. Hartshorn was a social worker who was involved in the provision of services for the aged in Brisbane and an early member of the Australian Association of Gerontology, see Chapter Five.
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APPENDICES
Appendix 1. Sample list of Geriatrics Conferences and participants,1964, 1969 and 1973, Geriatrics Conference 1956-1966, Geriatrics Conference 1967-1976, Hospitals and Charities Commission, Melbourne.
Conference: Community’s responsibility to aged, NZ view; Kew City Hall, 1964 Attended by: Visiting Med. Super, Chairman OPCW, Rehabilitation medicine, District Nursing Service, State representatives – 3 medical practitioners, 3 administrators, Visiting physician, Institutional Administrator, Social Worker, Architect Representing: Auckland, Melbourne, Canberra Hospital, Melbourne DNS, Medical – NSW, Qld, WA, Admin.- govt dept & institutional – Tas, Vic, SA, Royal Newcastle Hospital, Grace McKellar Hse Vic, Old People’s Welfare Council, State Government
Conference: Preventive approach to geriatrics; chiropody; the pattern of permanent care for the aged; dental problems in the aged; education for geriatric nursing; pastoral care Mount Royal 1969. Attended by: Foundation Prof Social & Preventive Medicine, Chiropodist, Director Council of Social Services, Dean Faculty Dental Science, Principal Nurse Educator, Minister of Religion Representing: Monash University, Consultant to Mount Royal Victoria, University of Melbourne, Mount Royal Hospital, Chaplain, Willsmere Hospital
Conference: Community health & care of the aged; voluntary agency institution; aspects of care of the frail aged; domiciliary care, Caulfield Hospital, 1973 Attended by: C/wealth Advisor in Geriatrics and Gerontology, Ass. Chief Health Officer, Med super., Community Health Educator, Panel of Nurse, Dentist, Chiropodist, Social Worker Representing: Commonwealth Govt., Community Services Dept.(no state noted), Freemasons’ Homes, Dept. Social & Preventive Medicine, Monash Univ., RDNS, Dental Hospital, Chiropodist to Methodist Dept of Adult Care, Medical Social Worker, Southern Memorial Hospital Melbourne
348 Appendix 2: Officer Bearers and Members of Council Australian Association of Gerontology, 1965 –1969, Newsletter of the Australian Association of Gerontology, vols 1, nos 2, 4, 7; Proceedings of the Australian Association of Gerontology, vol 1, no 1.
1965 following the First Congress of the Association Dr Sidney Sax (President) Sir William Upjohn (Vice President) Dr David Wallace (Secretary/Treasurer) Dr A. Everitt (Sydney) Dr B. F. Ford (Canberra) Dr. R. M. Gibson (Newcastle) Dr. J. A. Foster (Launceston) Miss S. Ramsey (Social Work, Melbourne) Dr. C. Robjohns (Adelaide) Dr A. Ungar (Sydney) Dr. R. M. Gibson (Newcastle) President
1966 Dr. D. Wallace (Goulbourn) Secretary Dr A. Everitt (Sydney) Dr B. F. Ford (Canberra) Dr. R. B. Lefroy (Perth) Dr. J. A. Foster (Launceston) Miss S. Ramsey (Social Work, Melbourne) Dr. C. Robjohns (Adelaide) Dr A. Ungar (Sydney) Dr. S. Sax (Sydney) Dr. P. Livingstone (Brisbane) Dr. S. Nelson (Sydney)
1967 Dr. R. M. Gibson (Newcastle) Pres. Dr. P. Livingstone (Brisb.) Vice-Pres. Dr. S. Sax (Sydney) Immediate Past President Mrs. R. Inall (Canberra) Honorary Secretary/Treasurer Dr. D. Wallace (Goulbourn) Dr A. Everitt (Sydney) Dr B. F. Ford (Canberra) Dr. R. B. Lefroy (Perth) Dr. J. A. Foster (L’ston) Miss D. Watkins (Melb, Geriatric Div. HCC) Dr. C. Robjohns (Adelaide) Dr S. Shepherd (Melbourne) Dr H. Bower (Melbourne) Dr K. Hirschfield (Qld)
1969 Dr. D.C. Wallace (Pres, NSW) Dr. S.J.H. Shepherd (Vice Pres, Vic) Dr R.M. Gibson (Newcastle) Mrs E.W. Cooper (New South Wales) Dr. B. Ford (Canberra) Dr A.J. Forster (Tasmania) Dr. R. Greenlees (South Australia) Miss H. Ryan Dr. S. Sax (New South Wales) Miss D. Watkins (Victoria) Dr J.C. Brierley (New South Wales) Dr. K. Hirschfeld (Queensland)
349 Apppendix 3 Summary of provisions for elderly Australians in 1975, from, R. Mendelsohn, The Condition of the People, Social Welfare in Australia, 1900-1975, George Allen & Unwin, Sydney, 1979, p187.
‘At the Australian Government level the measures have included the regular increasing of the maximum pension; the provision of supplementary assistance for rent or board; free medical, hospital and pharmaceutical benefits subject to means tests; the provision of repatriation benefits; subsidising the construction of ‘approved’ accommodation, care in nursing homes, domestic assistance, senior citizens’ centres, and ‘meals-on-wheels’; and the provision of various other benefits such as telephone rental concessions and special tax relief. At the same time the estates, the private health sectors, the voluntary and charitable organisations and to a lesser extent local governments have provided most of the direct services. For example, the states have retained prime responsibility for hospitals and health services, public housing, public institutions for the aged and other welfare services. The voluntary sector has played a significant role in sponsoring and running aged persons’ homes, ‘meals-on-wheels’ and home nursing, and the private sector has provided primary medical care and nursing homes.’ Local governments have also sponsored aged person’s homes and some provide facilities and services such as senior citizens’ centres, ‘meals-on- wheels’ and domestic assistance. Most local governments provide some for of rate concessions, by the deferment or remission of rates, for aged people with limited means. The responsibility for services to the elderly, therefore, is scattered throughout all levels of government, the voluntary organisations and the private sector.’
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Minerva Access is the Institutional Repository of The University of Melbourne
Author/s: HUNTER, CECILY ELIZABETH
Title: Doctoring old age: a social history of geriatric medicine in Victoria.
Date: 2003-02
Citation: Hunter, C. E. (2003). Doctoring old age: a social history of geriatric medicine in Victoria. PhD thesis, Department of History and Philosophy of Science, University of Melbourne.
Publication Status: Unpublished
Persistent Link: http://hdl.handle.net/11343/38755
File Description: Doctoring old age: a social history of geriatric medicine in Victoria.
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